3k 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 

Gift  of 
Dr.  E.  R.  Earwood 


I.EIHWK 


TABLET  TO  CRAWFORD  W.  LONG 

First  to  use  ether  as  an  anaesthetic  in  surgery,  March  30,  1842. 


THE  ART 

OF 

ANAESTHESIA 


BY 

PALUEL  J.  FLAGG,  M.D. 

LECTURER  IN  ANESTHESIA,  FORDHAM   UNIVERSITY   MEDICAL  SCHOOL,  ANAESTHETIST  TO 

ROOSEVELT     HOSPITAL;     INSTRUCTOR     IN     ANAESTHESIA     TO      BELLEVUE     AND 

ALLIED    HOSPITALS,  FOKDHAM    DIVISION;  CONSULTING   ANESTHETIST 

TO  ST.  Joseph's  hospital,  yonkers,  n.y.  formerly  anes- 
thetist TO  the  woman's  hospital,  new  YORK  CITY 


136  ILLUSTRATIONS 


PHILADELPHIA  AND  LONDON 
J.  B.  LIPPINCOTT  COMPANY 


COPYRIGHT,    I916,    BY    J.    B.    LIPPINCOTT   COMPANY 


ElectTotyped  and  Printed  by  J.  B.  Lipfincott  Company 
At  the  Washington  Square  Press,  Philadelphia,  U.  S.  A. 


200 


To 

I.  H.  S. 

My  Dearest  Master 

this  book 
Is  Humbly  Dedicated 


624469 


PREFACE 

The  proper  administration  of  an  anaesthetic  is  more 
than  a  mere  mechanical  performance,  it  is  an  art. 

The  Art  of  Atuvsthesia  is  acquired  by  becoming  famil- 
iar with  the  laws  which  govern  its  administration  and  by 
developing  the  ability  to  proj^erly  correlate  and  apply  these 
laws. 

It  will  be  perceived  that  while  a  knowledge  of  laws  is 
essential,  yet  this  knowledge  is  suj^erseded  by  the  ability 
to  properly  apply  them.  This  controlling  element  is  what 
constitutes  the  essence  of  the  art.  Experience  begets  dex- 
terity, tact  and  skill.  These  qualities,  while  somewhat 
intangible,  are  nevertheless  indispensable.  They  imply  a 
correct  and  spontaneous  response  to  the  demands  of  the 
patient. 

The  Art  of  AncestJiesia  is  not  contained  within  any 
particular  mode  of  administration.  So-called  empirical, 
percentage  and  shock-absorbing  methods  have  their  f)lace, 
but  should  not  be  j)ermitted  to  dominate  over  the  art  in  its 
broader  sense.  They  are  its  tools  and  must  be  observed 
from  a  point  of  view  which  considers  the  surgeon,  the  pa- 
tient, the  time,  the  place  and  many  other  factors. 

Since^amiliarity  breeds  contempt,  the  anaesthetist  must 
never  forget  to  approach  each  case  with  a  certain  degree  of 
courtesy  and  respect,  for  the  possibilities  of  success  as  well 
as  of  failure  in  each  are  almost  unlimited. 

A  thousand  ana?sthesias,  instead  of  leading  to  crude- 
ness,  should  make  one  a  thousand  times  more  careful.  As 
one  proceeds,  one  should  try  to  formulate  laws,  and  these 
one  should  strive  to  prove  by  the  next  case. 


vi  PREFACE 

The  Art  of  Anccsthesia  implies  an  intimate  knowledge 
of  general  medicine,  pathology,  sm*gery,  therapeutics,  psy- 
chology and  special  branches.  Those  who  are  not  familiar 
with  these  subjects  cannot  understand  the  language  of 
anaesthesia. 

For  example,  how  can  a  lay  person  intelligently  form 
an  opinion  upon  such  vital  matters  as  acidosis,  toxaemia, 
carbon  dioxide,  stimulation,  and  depression?  How  can  he 
unravel  and  relieve  the  untoward  symptoms  which  might 
arise  in  a  case  complicated  by  respiratory  obstruction,  mor- 
phine depression,  and  reflex  inhibition? 

Death,  due  to  anaesthesia,  is  not  an  unheard-of  thing  in 
lay  conversation.  As  a  consequence  some  timidity  exists 
towards  the  taking  of  an  anesthetic.     Intelligent  people 

often  ask:  "  How  does  Dr.  know  that  I  can  safely 

take  an  anesthetic?  "  This  fairly  common  query  implies 
not  only  the  necessity  of  a  preliminar}^  examination,  but  of 
an  examination  by  a  physician.  Aside  from  this  consid- 
eration, a  surgeon  can  ill  afford  to  let  the  public  know  that 
he  is  willing  to  risk  the  patient's  life  at  the  hands  of  an 
anesthetist  who  is  not  a  medical  man.  Does  not  this  very 
evident  lack  of  concern  imply  to  the  mind  of  the  thought- 
ful patient  a  greater  lack  of  care  which  ma}'  include  the 
operative  procedure  ? 

A  layman  who  administers  an  anesthetic  is  like  a  blind 
guide  who  is  led  by  the  patient,  instead  of  leading  him. 
Unable  to  properly  anticipate  the  stages  of  an  operation 
he  cannot  judge  the  indications  for  artificial  stimulation. 

Those  who  relegate  anesthesia  to  the  layman,  place 
the  responsibility  of  the  outcome  on  their  own  shoulders. 

To  give  an  anesthetic  is  one  thing,  to  practice  the  Art 
of  Ancethesia  is  another. 


PREFACE  vii 

This  book,  therefore,  is  intended  as  a  groundwork,  upon 
which  the  student,  interne,  and  general  practitioner  may 
acquire  a  more  comprehensive  knowledge  of  the  Art  of 
Anaesthesia.  Without  an  understanding  of  the  broad 
truths  which  underlie  present  day  an<Tsthetization,  clinical 
experiences  and  reference  reading  will  lose  nmch  of  their 
value. 

It  is  proposed  to  describe  anaesthesia  as  the  student  will 
actually  find  it. 

The  history  of  amesthesia  has  been  briefly  considered. 
A  resume  of  the  entire  field  of  anaesthesia  is  then  attempted 
by  defining  and  describing  general,  local  and  micced  anaes- 
thesia. General  anaesthesia  is  then  taken  up  in  detail.  A 
classification  of  the  stages  of  amesthesia  based  upon  cir- 
cumstances present  in  all  methods  and  by  all  anaesthetics 
is  nmch  to  be  desired.  It  has  been  found  in  practice  that 
a  classification  made  up  of  the  stages  of  induction,  main- 
tenance and  recovery  meets  these  requirements  admirably. 
SiicR~a  classification~is' easily  demonstrated  and  grasped. 
At  the  conclusion  of  an  elaboration  of  these  stages  we  have 
appended  a  summary,  which  will  be  found  valuable  for 
reviewing  and  quizzing  purposes. 

The  classification  of  the  stages  of  amesthesia  forms  a 
basis  upon  which  we  may  intelligently  attack  the  problem 
of  the  signs  of  ansesthesia.  Ether  being  the  most  widely 
used  anieesthetic,  we  have  thought  it  wise  to  use  this  type 
of  aneesthesia  as  a  basis. 

The  classification  of  the  stages  of  arucsthesia  forms  a 
basis  upon  which  to  consider  the  administration  of  ether 
ancesthesia.  The  various  methods  employed,  oral  insuf- 
flation, intrapharyngeal  insufflation,  intratracheal  insuffla- 
tion, rectal  and  intravenous  methods  are  fullv  discussed. 


viii  PREFACE 

General  anaesthesia  by  ethyl  chloride,  chloroform,  ni- 
trous oocide,  nitrous  oxide  and  o.rijgen,  and  nitrous  oxide 
oxygen  ether  are  then  taken  up,  the  stages  of  amesthesia 
in  each  case  forming  a  common  basis  for  the  administra- 
tion and  the  signs  described. 

In  accordance  with  the  resume  suggested  above,  local 
anaesthesia  is  then  discussed.  A  chapter  on  mixed  or  spinal 
anaesthesia  follows. 

Medication  preliminary  to  anaesthesia  is  next  taken  up. 
This  is  followed  by  a  chapter  on  carbon  dioxide  and  re- 
breathing.  Bearing  in  mind  the  needs  of  the  general 
practitioner,  a  chapter  on  emergency  anaesthesia  has  been 
prepared.  Last,  but  not  least,  we  recommend  the  patient's 
point  of  view  to  the  earnest  angesthetist. 

The  collection  of  table  positions  which  are  presented  in 
connection  with  the  classification  of  the  stages  of  amesthe- 
sia is,  it  is  believed,  quite  complete. 

Chapters  I,  II,  III,  IV,  XIII,  XIV,  XVIII  and 
XX  have  been  written  with  the  needs  of  the  trained  nurse 
in  mind. 

In  conclusion  the  author  wishes  to  take  this  oppor- 
tunity to  thank  Dr.  G.  W.  Crile  for  the  hospitality  ex- 
tended him  while  in  Cleveland,  during  which  visit  he  was 
enabled  to  study  the  method  of  anoci  association,  so  earn- 
estly and  constantly  advocated  by  his  charming  host.  He 
is  also  indebted  to  Dr.  John  B.  Murphy  for  courtesies 
extended  while  visiting  his  clinic  in  Chicago,  and  is  under 
deep  obligations  to  Dr.  Charles  Mayo  for  a  delightful  visit 
to  his  remarkable  clinic ;  to  the  gentlemen  of  the  American 
Surgical  Society  indebtedness  is  expressed  for  many  privi- 
leges extended  while  visiting  in  the  West. 

To  Dr.  C.  N.  Dowd  the  author  is  indebted,  not  only 


PREFACE  ix 

for  innumerable  courtesies,  but  for  the  help  which  he  has 
offered  in  curtailing  crudeness  in  this  book ;  to  Dr.  Lucius 
Hotchkiss  for  having  made  much  of  this  book  possible ;  to 
Dr.  Karl  Connell  for  having  explained  the  use  of  the 
An^esthetometer,  and  for  the  loan  of  original  illustrations ; 
to  Dr.  L.  Booth  for  illustrations  on  intratracheal  insuffla- 
tion. To  the  Attending  Staff  of  Fordham  Hospital 
and  to  the  Faculty  of  Fordham  University  Medical 
School  indebtedness  is  acknowledged  for  nmch  encourage- 
ment and  support,  as  well  as  to  the  Attending  Staff  of  the 
Woman's  Hospital,  with  whom  many  pleasant  hours  have 
been  passed. 

Acknowledgment  is  made  to  Dr.  K.  Dwight  for  assis- 
tance in  the  classification  of  the  stages  of  anesthesia.  To 
Berchman  Bittl,  O.  M.  Cap.,  and  an  old  friend  Robert 
Getty  for  reading  the  proofs.  To  Dr.  A.  Bruno  for  assis- 
tance in  preparing  many  of  the  illustrations.  To  Dr.  L. 
De  Yoe  for  preparing  the  index.  To  the  daughters  of 
the  late  Dr.  C.  W.  Long,  the  discoverer  of  ether  anaes- 
thesia, grateful  acknowledgment  is  made  for  photographs 
and  pamphlets  relating  to  the  discovery  of  ether  anaesthesia. 

For  the  loan  of  illustrations  credit  is  due  Apj^leton 
&  Co.,  The  Modern  Hospital  Magazine,  The  Journal  of 
the  American  Medical  Association  and  Old  Penn. 

Finally  to  J.  B.  Lippincott  Co.  gratitude  is  expressed 
for  the  patience  and  courtesy  which  they  have  shown  in 
the  preparation  of  this  book. 

P.  J.  F. 
120  Central  Park  South, 
New  York  City. 


CONTENTS 


PAGE 

Introduction  (History) 1 

PART  I 

Bearing  Upon  the  Classification  of  An.esthesl\,  Its  Characteristic  Signs 
AND  Its  Administration  by  the  Various  Methods  Ordinarily  Employed 

Types  of  Anesthesia 
a.  general  anaesthesia.     b.  local  an.esthesia.     c.  mixed  an.esthesia. 

a.  general  an.esthesia 

CHAPTER 

I.  General  .\n.esthesia 11 

1.  Complete.    2.  Incomplete. 

II.  General  Anesthesia     A  Detailed  Consideration 15 

1.  Induction.    2.  Maintenance.    3.  Recovery. 

III.  Signs  of  An.esthesia 82 

1.  Respiration.    2.  Color.    3.  Muscle.    4.  Eye.    5.  Pulse. 

IV.  Ether  .\n.esthesia.    General  Consider.\tions 120 

1.  Oral  Insufflation.     2.  Intrapharyngeal.     3.  Intratracheal.     4.  Oil 
Ether  Rectal.    5.  Intravenous. 

V.  Ethyl  Chloride 181 

General  Consideration.    Technic  of  Administration. 

VI.  Chixjroform 185 

General  Consideration.    Technic  of  Administration. 

MI.  Nitrous  Oxide 201 

General  Consideration.    Technic  of  Administration. 

VIII.  Nitrous  Oxide  Oxygen  Anesthesia 214 

General  Consideration.    Technic  of  Administration. 

IX.  Nitrous  Oxide  Oxygen  Ether  Anesthesia 223 

General  Consideration.     Technic   of    Administration.     Anoci    Asso- 
ciation. 

B.  local  anesthesia 

X.  Unusual  Methods 249 

1.  By  Freezing.    2.  By  Pressure.    3.  By  Regional  Intravenous  Injec- 
tions of  Novocaine. 

XI.  Usual  Methods 255 

1.  By  Surface  Application.      2.  By  Infiltration  Anaesthesia.      3.  By 
Conductive  Anaesthesia. 

c.  mixed  anesthesm. 

XII.  General  Consideration 261 

XIII.  Method  of  Administration 265 


xii  CONTENTS 

PART  II 

Bearing  Upon  Factors  Incidental  to  the  Actual  Administration  of  the 

Anesthetic 
chapter  page 

XIV.  Preliminary  Medication  in  An.esthesia 277 

XV.  Post-Operative  Treatment  of  the  Patient;  Duties  of  the  Nurse 

Before,  During  and  After  Anesthesia 285 

XVI.  Carbon  Dioxide  and  Rebreatiiixg 296 

XVII.  Emergency  Anesthesia 308 

XVIII.  The  Anesthetist's  Records 318 

XIX.  Aspirators 321 

XX.  The  Point  of  View  of  the  Patient 328 

Bibliography 325 

Index 337 


ILLUSTRATIONS 

fh;.  page 

Tablet  to  Crawford  W.  Long Frontispiece 

1.  Homer 3 

2.  Du  Bartiis 3 

3.  Shakespeare 3 

4.  Dr.  C.  W.  Long 3 

5.  A  Documentary  Reference  to  the  Existence  of  Ether  Frolics 4 

6.  The  First  Suggestion  of  the  Use  of  Ether  as  an  Ansesthetic 4 

7.  An  Account  of  the  First  Aniesthesia 4 

8.  Long's  Discovery  no  Secret  5 

9.  Curve  of  Complete  Ana-sthesia 1'2 

10.  Curve  of  an  Incomplete  Ansesthesia 13 

11.  Correct  Control  of  the  Head,  the  Patient  Across  the  Bed 24 

12.  Incorrect  Control  of  the  Head,  the  Patient  Parallel  with  the  Bed 24 

13.  The  Boxwood  Mouth  Wedge 34 

14.  The  Author's  Modification  of  the  Council  Throat  Tube 34 

15.  Throat  Tube  in  Place 35 

16.  Table  in  Trendelenburg  Position 38 

17.  Patient  Ready  for  Trendelenburg  Position 38 

18.  Patient  in  Trendelenburg  Position 39 

19.  Table  in  Position  for  Trendelenburg  Position — Feet  Straight  39 

20.  Patient  in  Trendelenburg  Position — Feet  Straight 41 

21.  The  Simms  Position 41 

22.  Position  Favoring  Brachial  Paralysis 43 

23.  Position  Favoring  Musculospiral  Paralysis 43 

24.  Position  for  Exploration  of  Knee-joint 44 

25.  Prone  Position 44 

26.  Prone  Position  for  Sacral  Operation 45 

27.  Position  for  Operation  on  Sacrum 45 

28.  Table  with  Gall-bladder  Kidney  Rack  in  Position 46 

29.  Patient  in  Kidney  Position  Over  Rack 46 

30.  Patient  in  Gall-Bladder  Position  Over  Rack 49 

31.  Table  Broken  Instead  of  Raising  Rack 49 

32.  Kidney  Position  on  Broken  Table 50 

33.  Gall-bladder  Position  on  Broken  Table 50 

34.  Ordinary  Neck  Position  for  Goitre  Operation 51 

35.  Ordinary  Xeck  Position  for  Glands  of  Xeck 51 

36.  The  Rose  Position 52 

37.  The  Elevated  Xeck  Position 52 

38.  The  Table  Set  for  Elevated  Xeck  Position 53 

xiii 


xiv  ILLUSTRATIONS 

39.  Patient  in  Elevated  Neck  Position 53 

40.  Table  Set  for  Lithotomy 55 

41.  Patient  in  Lithotomy •  •  •  55 

42.  Table  Set  for  Closure  of  Upper  Abdominal  Wounds 56 

43.  Patient  in  Position  for  Closure  of  Upper  Abdominal  Wounds 56 

44.  The  Walcher  Position 57 

45.  Diagram  to  Explain  the  Walcher  Position 58 

46.  Curve  Showing  Variable  and  Constant  Maintenance 61 

47.  Diagram  Showing  Vapor  Tension  of  Ether  in  Alveolar  .\ir  During  the  Three 

Stages  of  a  Complete  Anaesthesia 65 

48.  Vapor  Pressure  of  Ether  in  Tidal  Air  for  Induction  and  Maintenance  of 

Full  .\nsesthesia 6H 

49.  Plot  of  Ether  Vapor  Pressure  in  Pulmonary  Tidal  Air 69 

50.  Plot  of  Ether  Tension  in  Body 70 

51.  Zones  of  Ether  Anaesthesia 73 

52.  Recovery  by  Crisis 76 

53.  Recovery  by  Lysis 77 

54.  Gauze  on  Upper  Lip  Moistened  with  Essence  of  Orange 80 

55.  56.  Sylvester  Method— Artificial  Respiration 93,  94 

57.  Simple  Form  of  Mercury  Manometer 95 

58.  Lewis  Pendulum  Swing 96 

59.  Normal  Movements  of  Diaphragm 104 

60.  Movement  of  Diaphragm  Before  a  Fatal  Issue 104 

61.  Diagram  Showing  Enervation  of  the  Dilator  and  Sphincter  Pupilse 109 

62.  63.  Intravenous  Administration  of  Saline 115, 116 

64.  Hypodermoclysis 118 

65.  Yankauer  Gwathmey  Drop  and  Vapor  Mask 123 

66.  Making  the  Ether  Drop  Bottle 124 

67-71.  Ether  by  the  Semi-open  Drop  Method 128-131 

72.  The  .\uthor's  Apparatus  for  the  .\dministration  of  Ether  by  the  Closed  Drop 

Method  and  for  Gas  Oxygen  Ether  Anaesthesia 134 

73.  Wire  Gauze  Roll 135 

74.  75.  Bennett  .\pparatus 139 

76.  Apparatus  for  the  Vapor  Method  of  Oral  Insufflation  and  for  Intrapharyngeal 

Insufflation  Where  Concentrated  Vapor  of  Small  Volume  is  Employed ...    147 

77.  Vapor  Mask 148 

78.  Anaesthetometer 150 

79.  Foot  Bellows 151 

80.  Steam  Pump  for  Air  Supply  at  Roosevelt  Hospital .    152 

81.  Large  Reservoir  Tank  and  Wash  Tank  into  Which  Air  from  Steam  Pump  is 

Delivered  before  being  Piped  to  the  Operating  Rooms 152 

82.  Electrical  Unit  (Connell) 153 

83.  Nasal  Tubes 154 

84.  Nasal  Tube  in  Place 154 


ILLUSTRATIONS  xv 

85,  86.  Intrapharyngeal  Anaesthesia 155 

87.  Portable  Anacsthetometer • 161 

88.  Intratracheal  Catheter 162 

89.  Jackson  Laryngoscope  and  Rheostat 163 

90.  91.  Intratracheal  .Vnivsthesia 165-166 

92.  Intravenous  Apparatus 177 

93.  Chloroform  Containers 182 

94.  Ethyl  Chloride  Container,  Spray  Type ". 182 

95.  Various  Sizes  \20  Tanks,  100-3200  Gallons 202 

96.  Reducing  Valve 203 

97.  Label  on  NoO  Cylinder 204 

98.  Plan  of  Apparatus  Installed  in  Lakeside  Hospital  for  the  Manufacture  of 

Nitrous  Oxide 205 

99.  The  Author's  Cylinder  Holder 209 

100.  The  Author's  Cylinder  Holder  Clamped  to  the  Edge  of  a  Table 210 

101.  Cylinders  Lying  on  a  Chair  Supported  by  the  Author's  Holder 211 

102.  Cylinder  Clamp  Fa.stened  to  a  Window-sill 212 

103.  A  Simple  Wooden  Stand  for  Three  Cylinders,  Suitable  for  Hospital  Use 215 

104-105.  Face  Piece  and  Controlling  Valves 230 

106.  Face  Piece,  Miller  Apparatus 231 

107.  Miller  Apparatus 232 

108.  Zones  of  Nitrous  Oxide  Oxygen  Anaesthesia  in  Normal  Man  without  Sup- 

plemental Narcosis 234 

109.  Connell  Nitrous  Oxide,  Oxygen,  Ether  Flow  Control 235 

110.  Esmarch  Bandage 251 

111.  112.  Bandage  for  Regional  Intravenous 253 

113.  Case  Containing  Outfit  for  Intraspinal  and  Local  Anaesthesia 257 

114.  Relative  Sensitiveness  of  Tissues 259 

115.  The  Relations  of  the  Lumbar  and  Dorsal  Interspaces  to  the  Crests  of  the 

Ilia  and  Lower  Ribs 266 

116.  Localization  of  the  Spinal  Interspaces 267 

117.  The  Point  of  Skin  Puncture  is  Anaesthetized  by  Freezing 269 

118.  The  Needle  is  Introduced  in  the  Middle  Line  Forward  and  Inward 270 

119.  As  the  Dura  is  Pierced,  the  Cerebrospinal  Fluid  Escapes  and  May  be  Col- 

lected in  Test-tube  for  Further  Study 271 

120.  The  Syringe  Containing  the  Proper  Dose  of  Stovaine  is  Attached  to  the 

Needle  and  Slowly  Injected ., 272 

121.  Nurse  Grasping  Patient's  Wrists 286 

122.  The  Fowler  Position 292 

123.  The  Shock  Position 293 

"  124.  Tracing  of  Experiment  in  Respiration 306 

125.  Making  the  Cone ". 313 

126.  Funnel  with  Tube  for  Intrapharyngeal  Anaesthesia 315 

127.  Funnel  with  Tube  for  Intratracheal  Anaesthesia 316 


xvi  ILLUSTRATIONS 

128.  Front  of  Anaesthesia  Record  Card 318 

129.  Reverse  of  Anesthesia  Record  Card 319 

130.  Foot  Aspirator 322 

131.  Water  Aspirator 323 

132.  Electrical  Aspirator 324 

133.  Ejector  for  Steam  Aspirator 324 

134.  The  Steam  Pump  Aspirator  Complete  with  Aspirating  Tongue  Depressor. ,  .  325 

135.  Aspirating  Tongue  Depressor 326 


THE  ART  OF  ANESTHESIA 

INTRODUCTION 

THE  HISTORY  OF  ANAESTHESIA 

The  history  of  anaesthesia  may  be  broadly  divided  into 
two  periods :  the  pre-ancesthetic  peiiod  and  the  ancesthetic 
period.  The  pre-ana^sthetic  period  ends  and  the  ancesthetic 
period  begins  with  the  discovery  of  ether  in  1842  and  its 
general  introduction  in  1846. 

THE  PRE-AN^STHETIC  PERIOD 
(Before  1842) 

The  beginning  of  the  use  of  anaesthesia  is  not  known ;  it 
dates  from  the  earliest  antiquity.  The  following  com- 
monly accejDted  references  prove  that  narcotics  were  used 
in  pre-ancesthetic  times. 

Homer  (Fig.  1),  in  "The  Odyssey,"  says:  "Helen 
dropped  into  the  wine  of  which  (the  soldiers)  drank  a 
drug,  an  antidote  of  grief  and  pain  inducing  oblivion  to  all 
ills.  He  who  drinks  of  this  mingled  cup  sheds  not  a  tear 
the  livelong  day  were  death  to  seize  his  venerated  sire  or  her 
who  gave  him  birth,  or  were  the  sword  buried  in  the  bosom 
of  his  brother  or  greatly  loved  sister,  no  tear  would  even 
then  bedew  his  cheeks." 

In  484  B.C.,  Herodotus  refers  to  the  inhalation  of  the 
vapors  of  hemp  (Cannabis  Indica)  to  produce  intoxication. 

In  23  A.D.,  Pliny,  the  Roman  author,  speaks  of  the  juice 
of  certain  leaves  taken  before  cuttings  and  burning  to  pro- 
duce sleep. 


2  AN^STHESL\ 

In  134  A.D.,  Galen,  the  physician,  speaks  of  the  power 
of  mandragora  to  j^aralyze  sensation  and  motion. 

In  2v50  A.D.,  Lucian,  the  Greek  historian,  refers  to  the 
narcotic  effects  of  mandragora. 

In  1250,  Hugo  de  Luca,  physician,  refers  to  a  certain 
oil  with  which  he  put  patients  to  sleep  before  operations. 

In  1.544  Du  Bartas  implies  a  custom  by  writing: 

Even  as  a  Surgeon,  minding  off  to  cut 
Some  cureless  limb,  before  in  use  he  put 
His  violent  engines  on  the  viscious  member 
Bringeth  his  patient  in  a  senseless  slumber. 

In  1613,  Shakespeare  (Fig.  3)  in  "  Cymbeline,"  Act  I, 
Scene  VI,  implies  the  use  of  a  narcotic.  (Cornelius  plans 
to  giye  a  secret  drug  which) 

Will  stupify  and  dull  the  sense  awhile, 

No  danger  in  what  show  of  death  it  makes. 

In  1772,  Priestly  discovers  nitrous  oxide. 

In  1804,  Sir  Humphrey  Davy  suggests  the  use  of  ni- 
trous oxide  as  an  ansesthetic. 

In  1818,  Faraday  notes  resemblance  between  nitrous 
oxide  and  ether. 

The  narcotic  effects  secured  in  ancient,  mediaeval  and 
modern  times,  during  the  period  which  we  have  designated 
as  pre-cincesthetic  (previous  to  1842),  were  brought  about 
chiefly  by  the  use  of: 

Mandragora  root  (related  to  belladonna). 

Cannabis  indica,  a  certain  kind  of  hemp,  smoked  as 
haschisch. 

Secret  Chinese  mixtures. 

Pressure  on  blood-vessels  and  nerve  trunks. 

Hypnotism. 

The  ancesthetic  period  was  foreshadowed  by  the  spora- 
dic use  of  nitrous  oxide  both  in  England  and  America.  At 
about  this  time  it  became  a  common  practice  for  persons  to 


INTRODUCTION 


Fig.  1. — Homer. 


Fig.  2.— DuBartas. 


Fig.  3.— Shakespeare. 


Fig.  4. — Dr.  C.  W.  Long,  from  a  crayon 

drawinje  made  in  1S42. 

(Courtesy  of  Florence  Long  Bartow.) 


Homer,  Du  Bartas  and  Shakespeare,  Poets  of  the  pre-anjesthetic  period  who  wrote  of  the  use  of  narcotic 

for  the  control  of  pain.    Dr.  C.  W.  Long,  of  Georgia,  who  opened  the  anjesthetic  period  by  employing 

ether,  to  secure  unconsciousness  during  an  operation  which  he  performed  in  the  spring  of  1842. 


4  ANESTHESIA 

inliale  the  fumes  of  ether  for  the  exhilarating  effects.  This 
practice  sometimes  formed  the  chief  entertainment  at  coun- 
try parties.  These  ether  frolies  probahly  suggested  the  use 
of  this  agent  as  an  anaesthetic,  for  during  these  frohcs,  the 
stage  of  excitement  occasionally  led  to  unconsciousness  and 
loss  of  sensation.  A  portion  of  a  document,  sworn  to  by 
one  R.  H.  Goodman  of  Georgia,  shown  in  Fig.  5,  "  refers 
to  these  ether  frolics." 

THE  ANAESTHETIC  PERIOD 
(From  1842  to  the  present  time) 

The  proper  discovery  of  auccsthesia  involves  the  names 
of  four  investigators:  Crawford  W.  Long  of  Georgia; 
William  T.  Morton  of  Hartford ;  Horace  Wells  of  Hart- 
ford and  Charles  T.  Jackson  of  Boston. 

Dr.  Crawford  Long  (Fig.  4)  of  Georgia,  having  ob- 
served the  loss  of  sensation  incidental  to  injuries  received 
during  ether  frolics,  concluded  that  sulphuric  ether  might 
well  be  used  to  allay  the  pain  of  surgical  operations.  This 
idea  occurred  to  Dr.  Long  late  in  the  year  1841,  as  may  be 
seen  in  Fig.  6.  In  the  spring  of  1842  Dr.  Long  put  his 
theory  into  practice.  After  having  rendered  his  patient, 
one  James  Venable,  unconscious  with  inhalations  of  ether, 
he  successfully  removed  two  small  tumors  from  the  man's 
neck.  The  documents  reproduced  in  Figs.  6  and  7  give 
brief  accounts  of  the  first  operation  ever  done  under  ether. 

H.  Wells  of  Hartford  had  a  tooth  extracted  under  the 
influence  of  nitrous  oxide.  He  subsequently  used  it  upon 
his  patients  with  such  good  results  that  he  attempted  a 
demonstration  at  the  Harvard  University  Medical  School. 
His  exhibition  was  a  failure  and  so  disheartened  him  that 
he  later  committed  suicide. 

W.  T.  Morton  was  a  student  under  Wells  and  conse- 


X//^^    «^r  ^^    /^ 


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^^CiUi^^r^(^     a^u^.  A^<-^^    /!^p^^^^^^^     '^-•^^^-   ^^^^^-^   c^^jf^ — ■ 

Courtesy  Dr.  Allen  J.  Sinitli.  Cild  Penn. 

Fro.  5. — KtlitT  frolic.     A  docunieiitiiiv  rcfereiice  to  tlic  existeiici'  iif  Ktlin-  Frulk-?:. 


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Courtesy  Dr.  Allen  I.  Smith,  (lid  Pcnn. 


Fig.  6. — The  first  suggestion  of  the  use  of  ether  as  an  anaesthetic. 


^<-<.-€.^.-^i^<^ 


<^^t^A/ 


''^^^t-ri.cS? 


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Courtesy  Dr.  Allen  J.  Smith,  Old  Penn. 


Fig.  7. — Aa  account  of  the  first  ansesthesia. 


^  ^^ 


5      <2-44v4^ 


INTRODUCTION  5 

quently  was  familiar  with  the  use  of  nitrous  oxide.  While 
serving  as  a  medical  student  under  the  preceptorship  of 
C.  T.  Jackson,  the  latter  suggested  that  he  use  ether  in 
place  of  nitrous  oxide.  ^Morton  did  so  and  after  several 
experimental  successes  gave  a  demonstration  at  the  ^Nlassa- 
chusetts  General  Hospital,  October  10,  1846. 

As  the  operator,  Dr.  Warren,  remarked  at  the  conclu- 
sion of  the  operation,  "  Gentlemen,  this  is  no  humbug,"  so 
subsequent  events  proved  this  public  demonstration  to  be 
the  birth  of  a  new  era.  The  crudeness  of  pre-ana?sthetic 
methods  is  vividly  depicted  by  Hayden,  who  describes  an 
operation  performed  on  a  woman:  "  With  a  meek,  implor- 
ing look  and  the  air  of  a  startled  fawn,  as  her  modest  gaze 
meets  the  bold  eyes  fixed  upon  her,  she  is  brought  into  the 
amphitheatre  crowded  with  men,  anxious  to  see  the  shed- 
ding of  her  blood,  and  laid  upon  the  table.  With  a  knowl- 
edge and  merciful  regard  as  to  the  intensity  of  the  agony 
which  she  is  to  suffer,  opiates  and  stimulants  have  been 
freely  given  her  which,  perhaps  at  this  last  stage,  are  again 
repeated.  She  is  cheered  by  kind  words  and  the  informa- 
tion that  it  will  soon  be  over  and  she  freed  forever  from 
what  now^  afflicts  her;  she  is  enjoined  to  be  calm  and  to  keep 
quiet  and  still;  and  with  assistance  at  hand  to  hold  her 
struggling  form,  the  operation  is  commenced. 

"But  of  what  avail  are  all  her  attempts  at  fortitude!  At 
the  first  clear,  crisp  cut  of  the  scalpel,  agonizing  screams 
bm*st  from  her,  and  with  convulsive  efforts  she  endeavors 
to  leap  from  the  table;  but  force  is  nigh.  Strong  men 
throw  themselves  upon  her  and  pinion  her  limbs.  Shrieks 
upon  shrieks  make  their  horrible  way  into  the  stillness  of 
the  room,  until  the  heart  of  the  boldest  sinks  into  his  bosom 
like  a  lump  of  lead. 

"  At  length  it  is  finished  and,  prostrate  with  pain,  weak 


6  ANAESTHESIA 

from  her  exertions  and  bruised  by  the  violence  used,  she 
is  borne  from  the  am^^hitheatre  to  her  bed  in  the  wards,  to 
recover  from  the  shock  by  slow  degrees." 

A  short  time  after  this  demonstration  at  the  Massachu- 
setts General  Hospital,  Morton  and  Jackson  patented 
ether  and  called  it  letheon.  The  secret  soon  leaked  out, 
however,  because  of  the  characteristic  odor  of  the  new  prep- 
aration. Petition  was  later  made  before  Congress  for 
recognition.  The  honorarium  consisted  of  one  hundred 
thousand  dollars.  Morton,  Jackson  and  a  friend  of  Wells, 
who  had  since  died,  became  claimants.  As  the  controversy 
was  about  to  close,  Jackson  recognized  the  claims  of  Long, 
which  had  just  been  received.  The  bill  was  thereupon 
dropped  and  never  again  presented. 

In  recalling  the  facts  pertaining  to  the  discovery  of 
ether  we  should  remember  that  Dr.  Crawford  Long  of 
Georgia  was  the  first  to  use  ether  as  an  anaesthetic.  He 
made  no  secret  of  his  discovery,  as  is  seen  in  Fig.  8,  but 
his  comparative  isolation  and  the  fact  that  he  had  no  large 
institutional  backing  prevented  his  discovery  from  becom- 
ing widely  known.  Four  years  later  the  use  of  ether  as  an 
anaesthetic  became  universal  through  the  sanction  which  its 
employment  received  at  the  IVIassachusetts  General  Hos- 
pital, where  it  had  been  introduced  by  INIorton  and  Jackson. 
In  the  following  year,  1847,  chloroform  was  introduced 
into  England  by  Sir  J.  Y.  Simpson.  The  employment  of 
nitrous  oxide  as  an  anaesthesia  by  H.  Wells,  in  1844,  fore- 
shadowed the  use  of  nitrous  oxide  and  oxygen  by 
E.  Andrews,  of  Chicago,  in  1868.  In  1844  Roller,  of 
Vienna,  introduced  cocaine.  Ethyl  chloride,  although 
recognized  as  an  auccsthetic  in  1847,  did  not  become  widely 
used  until  about  1900.  About  five  years  later  H.  Braun 
suggested  employment  of  novocaine  as  local  anaesthetic. 


PART  I 

BEARING  UPON  THE  CLASSIFICATION  OF 
ANAESTHESIA,  ITS  CHARACTERISTIC  SIGNS 
AND  ITS  ADMINISTRATION  BY  THE  VARIOUS 
METHODS   AND   AGENTS   ORDINARILY   EMPLOYED 


CLASSIFICATION  OF  ANESTHESIA 

GENERAL.  LOCAL.  MIXED.  OR  SPINAL 


COMPLETE  GENERAL  AN.ESTHESU 

0)  INDUCTION  {«)  MAINTENANCE 


Physiological  effects  of  the  ether 


Remsrlu  which  the  patieot  hea 


TttX.' 


(1)  INDUCTION 
rel&xatioD. 


.  Upper  abdaminsl  operatiuos. 


pennaneut 
uueatheatic. 


or  rigidity,  but  loe 


Affected  by  inductioo. 

Anicsthetist  aa  pilot. 
The  tteglECtcd  patit^nt — dies- 
Control  of  vomiting. 

Symptoms  of  patients  index 


Pharyagea) 
Rigidity 


aethwl  +  0  +  C(V 


IAddLk*' 
Obstruflcd  mpirntioii. 
Close  method  with  rynnosio, 

j  Vomiting  Rniahed  in  opcni(iD|j[  i 

Ilu  home  or  in  hoapilal. 
Time  of  return  of  ivnsciousness 
Recovery  with  cyanosis,  stimuli 
Recovaiy  with  pallor,  depjcasio; 
C«Dtro]  of  albctoiy  vomiting. 


PART  I 

ANESTHESIA— ITS  THREE  TYPES 

All  anesthesia  is  included  in  one  of  three  types: 
A,  general  anccsthesia;  B,  local  ancesthesia;  C,  mijced 
anccsthesia. 

General  Anaesthesia  is  that  type  of  anaesthesia  in 
which  tlie  central  nervous  system,  consisting  of  the  brain 
and  spinal  cord,  and  the  periplieral  nervous  system,  consist- 
ing of  afferent  nerves,  efferent  nerves  and  tactile  end 
organs,  are  brought  under  the  influence  of  the  amcsthetic. 

Local  Anaesthesia  is  that  type  of  anjesthesia  in  which 
only  the  peripheral  nervous  system  is  brought  under  the 
influence  of  the  anaesthetic. 

^IixED  Anaesthesia  is  that  type  of  anaesthesia  in  which 
the  spinal  cord  and  the  peripheral  nerves  are  brought  under 
the  influence  of  the  anaesthetic. 

GENERAL   ANESTHESIA 

In  order  to  produce  general  anasthesia,  it  is  necessary 
that  the  ana?sthetizing  su])stance  enter  into  the  general 
circulation.  Through  this  medium  only  can  the  higher 
centres  be  brought  under  control. 

General  anaesthesia  may  be  brought  about  indirectly 
as  follows: 

( 1 )  by  insufflation,  oral,  pharyngeal  and  intratracheal ; 
(2)  by  administering  the  drug  per  rectum.  Directly  as 
follows:  by  intravenous  anccsthesia. 

LOCAL  ANESTHESIA 
Local  anasthesia   is   the   ana?sthetization   of  the   end 
organs  or  nerve  trunks,  and  may  be  produced  by  the  fol- 

9 


10  ANAESTHESIA 

lowing  means:  (1)  by  freezing  the  part;  (2)  by  pressure 
on  the  nerve  trunks  or  by  pressure  producing  ischsemia  of 
the  part;  (3)  by  regional  intravenous  injections  of  novo- 
caine ;  ( 4 )  by  the  inj  ection  of  novocaine  or  some  other  drug 
into  the  skin  or  deeper  tissues. 

MIXED  ANESTHESIA 

Mixed  ancesthesia  is  the  anesthetization  of  the  spinal 
cord  and  nerve  trunks.  This  may  be  brought  about  by  in- 
jections of  novocaine,  tropacocaine  or  some  other  drug  into 
the  spinal  canal. 


CHAPTER  I 

A.  GENERAL  ANAESTHESIA  THE  FIRST  AND  MOST 
IMPORTANT  TYPE  OF  ANAESTHESIA 

There  are  two  classes  or  degrees  of  general  anaesthesia : 
complete  and  incomplete. 

COMPLETE  ANESTHESIA 

Let  us  first  identify  complete  amesthesia.  With  the 
clear  understanding  of  this  class,  there  will  be  no  difficulty 
in  understanding  incomplete  ancesthesia. 

Complete  ancesthesia  is  divided  into  three  distinct 
stages : 

(a)  The  stage  of  induction. 

(b)  The  stage  of  maintenance. 

(c)  The  stage  of  recovery. 

The  stage  of  induction  is  further  divided  into  three 
periods. 

[a)    The  period  of  excitement,  cerebral  and  mus- 
cular. 

[h)    The  period  of  rigidity. 
[c)    The  period  of  relaxation. 
The  stage  of  maintenance  is  not  subdivided. 
The   stage   of  recovery  is   further   divided   into   two 
periods : 

{a)  The  return  of  the  reflexes. 
( h )  The  return  of  consciousness. 
The  stage  of  induction  extends  from  the  beginning  of 
the  administration  of  the  anaesthetic  to  the  point  where 
general  muscular  relaxation  has  been  brought  about.  This 
stage,  leading  the  patient  as  it  does  from  consciousness  to 
deep  anaesthesia,  is  the  most  difficult  and  important  of  the 

11 


12 


ANAESTHESIA 


three  stages.  The  undervaluation  of  this  importance  is 
responsible  for  the  failures  which  one  sees  in  otherwise  un- 
complicated anaesthesias.  To  completelj^  induce  anaesthesia 
takes  from  six  to  eight  minutes.  The  correct  control  of 
this  stage  seriously  affects  the  stage  of  maintenance,  which 
is  to  follow. 

The  stage  of  maintenance  extends  from  the  completion 
of  relaxation  to  the  point  where  the  anaesthetic  level,  which 
has  been  carried,  is  permitted  to  drop,  with  a  view  of  allow- 
ing the  patient  to  recover. 


RELAXATION 


RlUlOlTY 


RETURN    or 
REFLEXES 


CXCiTEMENT 


RETURN   or 
CONSCIOUSNESS 


JJO 

MIN 

Fig.  9. — Curve  of  a  complete  ansesthesia. 


The  stage  of  maintenance  should  begin  just  before  the 
time  of  tjie  first  incision  and  should  cease  shortly  before 
the  conclusion  of  the  operative  procedure.  In  maintaining 
anaesthesia,  our  problem  is  to  supply  to  the  patient  the 
ether  which  he  loses  through  his  respiration,  exposed  capil- 
lary surfaces,  through  the  destruction  of  the  ether  radical, 
etc.,  after  anaesthesia  has  been  projDcrly  brought  about. 
While  strictly  speaking  there  are  no  periods  of  mainte- 
nance, yet  there  are  levels  of  lightness  and  depth  where 
certain  reflexes  may  be  retained  or  abolished. 

The  stage  of  recovery  is  the  inverse  of  the  stage  of 
induction. 


GENERAL  ANESTHESIA 


13 


The  stage  of  recovery  begins  when  the  constant  level, 
which  ha,s  been  carried  during  the  stage  of  maintenance ,  is 
permitted  to  permanently  drop  with  a  view  of  stopping  the 
administration  altogether.  The  stage  of  recovery  ends 
with  the  return  of  consciousness. 

Our  problem  in  this  stage  is  when  to  permit  its  appear- 
ance and  how  best  to  hasten  its  onset  and  completion. 

Induction  ana\sthetizes  the  patient. 

JNIaintenance  keeps  him  anaesthetized. 

Recovery  returns  him  to  consciousness. 

These  stages  forming  a  complete  anaesthesia  may  be 
represented  as  shown  graj^hically  in  Fig.  9. 

INCOMPLETE  ANESTHESIA 
The  term  incomplete  or  partial  anasthesia  may  be  ap- 
plied to  a  large  nmiiber  of  anaesthesias  induced  for  opera- 


RELAXAT 
(partial 


ION 

^absent) 


11 

Vv.     RETURN 

OF 

11 

VT        REFLEXES 

RIGIDITY        // 

'J'U 

//* 

<»'V\ 

I/O 

o\\ 

yi: 

''Av 

//^ 

<^XS-. 

RETURN   OF 

EXCITEMENT     J/^ 

^-Jvi 

CONSCIOUSNESS 

^ 

lO 

^5 

Fig.  10.— Curve  of  an  incomplete  anaesthesia. 

tions,  which  do  not  require  complete  relaxation,  and  which 
may  be  accomplished  in  a  short  period  of  time.  The  oj^en- 
ing  and  curetting  of  an  abscess,  or  the  dressing  of  a  wound 
may  be  done  with  perfect  satisfaction  to  surgeon,  patient 
and  angesthetist  in  the  presence  of  an  incomplete  ancesthesia. 


14  ANESTHESIA 

In  an  incomplete  ancesthesia  there  is  no  stage  of  7?iain- 
tenance.  This  stage,  it  will  be  remembered,  does  not  ap- 
pear until  general  relaxation  obtains.  Strietly  speaking, 
one  cannot  expect  the  patient  to  pass  from  consciousness 
to  the  period  of  excitement  or  rigidity  and  then  continue 
along  an  even  plane  at  the  convenience  of  the  anaesthetist. 
The  patient  will  either  become  light  and  vomit,  or  will  pass 
more  deeply  under  the  influence  of  the  anaesthetic  and  be- 
come relaxed. 

The  curve  of  an  incomplete  ancesthesia  may  be  repre- 
sented as  shown  in  Fig.  10. 

Before  starting  the  ancesthesia,  the  anccsthetist  should 
decide  the  question — Does  this  patient  require  complete  or 
incomplete  an cvsth esia ? 


CHAPTER  II 

THE  DETAILED  CONSIDERATION  OF  A  COMPLETE 
GENERAL  ANESTHESIA 

Complete  general  amesthesia  is  conveniently  divided 
into  three  stages:  induction,  maintenance  and  recovery. 

The  stage  of  induction  is  further  subdivided  into  three 
periods:  ejccitement,  rigidity  and  relaocation. 

I.  INDUCTION 

THE  PERIOD  OF  EXCITEMENT 

We  shall  now  take  up  in  detail  the  first  period,  that 
of  excitement,  touching  upon  its  evidences,  causes  and 
control. 

A.  The  Evidences  of  the  Period  of  Excitement. — 
Excitement  shows  itself  in  an  anxious  expression,  unusu- 
ally rapid  pulse,  irregular  sighing  respirations,  licking  of 
the  lips,  a  constant  clearing  of  the  throat  or  fidgety  move- 
ments of  the  hands  and  feet. 

A  woman  sometimes  complains  of  the  odor  of  the  ances- 
thetic  in  the  room  or  that  the  face  piece  is  uncomfortable. 
She  holds  her  breath  after  the  first  whiff  of  the  auccsthetic. 
This  is  often  followed  by  shallow  breathing  and  movements 
of  the  head  from  side  to  side.  Later,  she  may  talk,  laugh 
or  scream.  Following  a  period  of  fairly  satisfactory 
breathing,  she  may  suddenly  begin  to  struggle  violently, 
tearing  off  the  mask,  flexing  her  thighs  on  her  abdomen 
and  rolling  off  the  table  if  not  restrained.  In  a  man  tlie 
muscular  movements  frequently  begin  slowly  but  with 
great  strength,  requiring  the  combined  assistance  of  those 

15 


IC  ANAESTHESIA 

present  to  restrain  him.  Jactitation  or  convulsive  move- 
ments of  the  arms  or  legs,  grinding  of  the  teeth  and  expec- 
toration into  the  face  piece  are  not  uncommon.  In  chil- 
dren, bladder  movements  are  of  frequent  occurrence. 

B.  The  Causes  of  the  Period  of  Excitement. — 
Over-concentration  of  the  anaesthetic ;  lack  of  any  prepara- 
tion or  faulty  preparation;  temperament;  alcoholism;  ex- 
cessive smoking;  sexual;  remarks  which  the  patient  hears 
before  losing  consciousness;  physiological  effects  of  the 
ether ;  failure  to  understand  what  aneesthesia  means ;  nasal 
obstruction;  moving  patients  while  in  the  early  stages  of 
induction ;  excessive  fear,  especially  in  children,  and  pre\d- 
ous  unsatisfactory  anaesthesia,  are  all  causes  of  excitement. 

We  must  differentiate  excitement  per  se  and  the  sud- 
den determination  on  the  part  of  the  patient  to  have  the 
operation  postponed. 

If  the  patient  is  rational  and  has  not  received  any  of  the 
anaesthetic,  she  must  never  be  forcibly  anaesthetized.  Such 
a  procedure  may  give  grounds  for  a  suit.  In  this  connec- 
tion it  must  be  said  that  the  patient  should  never  be  anaes- 
thetized without  the  presence  of  one  or  more  witnesses. 

C.  The  Control  of  the  Period  of  Excitement. — 
Excitement  is  controlled  by  applying  indirect  and  direct 
means. 

The  Indirect  Control  of  the  Period  of  Excitement. — 
(a)  The  routine  preliminary  visit;  (h)  preliminary  diet 
and  medication. 

The  Boutin e  Preliminary  Visit. — The  preliminary  visit 
should  be  made  for  two  reasons:  first,  for  the  purpose  of 
physical  examination ;  second,  for  the  purpose  of  applying 
suggestive  therapeutics. 

In  making  the  physical  examination  there  are  at  least 
five  points  which  should  be  covered. 


COMPLETE  GENERAL  ArsvESTHESL\  17 

1.  Anaesthetic  history :  Was  the  j^atient  ever  anaesthe- 
tized before?  Was  the  course  of  anaesthesia  smooth  or 
stormy,  and  was  there  much  after-sickness? 

2.  Has  a  urine  examination  been  made?  If  so,  is  there 
sugar,  acetone  or  albumen  present? 

3.  Listen  to  the  chest ;  rule  out  or  determine  the  pres- 
ence of  tuberculosis,  bronchitis  or  asthma. 

4.  Examine  heart.  Note  whether  there  be  heaving 
apex  impulse,  tachycardia,  irregularity  in  rhythm  or  mur- 
murs. Note  color  of  \i])s  and  circulation  beneath  the  fin- 
ger-nails. The  i^atient  should  be  asked  to  hold  tlie  breath 
as  long  as  possible  in  the  manner  prescribed  as  follows:  He 
is  requested  to  breathe  deeply  two  or  three  times  through 
the  nose;  at  the  end  of  an  inspiration  the  nose  is  pinched 
by  the  anaesthetist  and  the  patient  is  asked  to  hold  the 
breath  as  long  as  possible.  If  it  is  impossible  for  him  to  do 
so  for  40  seconds,  acidosis  or  poor  cardiac  compensation 
may  be  suspected. 

The  anaesthetist  is  not  usually  considered  proficient  in 
physical  diagnosis.  He  has  exceptional  op^^ortunities  to 
become  so,  and  should  never  miss  the  opportunity  to  do 
thorough  work. 

5.  Look  into  the  mouth;  first,  that  you  may  observe 
false  teeth,  loose  teeth  or  chewing  gum;  second,  that  you 
may  become  familiar  with  the  manner  with  which  the  teeth 
approximate,  noting  the  best  position  for  the  insertion  of 
an  emergency  mouth  prop  or  gag. 

Suggestive  therapeutics  are  invaluable. 

The  patient  is  concerned  for  her  safety.  She  wishes 
you  to  assure  her  that  her  heart  is  "^  perfect/'  that  she  v/ill 
safely  pass  through  the  anaesthesia.  Your  questions  and 
physical  examinations  will  in  themselves  comfort  her,  and 


18  ANESTHESIA 

you  may  advance  your  negative  findings  as  proofs  of  her 
ability  to  take  the  anaesthetic.  Win  her  confidence  and  you 
will  have  done  much  to  control  the  period  of  excitement  and 
to  lessen  shock. 

Preliminary  Diet  and  Medication. — Morning  opera- 
tions are  more  satisfactory  than  those  done  later  in  day. 

Suppose  an  operation  for  appendectomy  to  take  place 
Monday  morning  at  9.00  a.m.  At  the  preliminary  visit, 
which  may  be  Saturday  evening,  an  ounce  of  castor  oil  is 
ordered  to  be  taken  at  bedtime.  Sunday,  the  usual  diet 
is  permitted,  and  in  addition  half  a  pound  of  some  good 
candy  is  suggested.  By  supplying  an  excess  of  glucose, 
candy  helps  to  neutralize  the  acidosis  caused  by  the  anaes- 
thetic. This  treatment  is  harmless  to  those  with  normal 
digestion,  and  is  usually  most  grateful  to  the  patient.  If 
she  is  a  poor  sleeper,  restless  and  apprehensive,  she  should 
receive  7  gr.  veronal  in  hot  milk  before  retiring  Sunday 
night.  She  should  be  encouraged  to  sleep  as  late  as  possi- 
ble Monday  morning.  Should  she  wake  at  7.00,  she  may  re- 
ceive a  cup  of  light  broth  but  no  solid  food.  At  8.30,  a 
hypodermic  of  1/6  gr.  morphine  sulphate  and  1/150  gr. 
atropine  should  be  given. 

We  are  now  confronted  by  the  question — where  shall 
we  induce  the  anaesthesia?  It  may  be  done  in  one  of  four 
places:  (1)  in  the  patient's  bed;  (2)  in  the  anaesthetizing 
room  on  a  stretcher;  (3)  on  the  operating  table  in  the 
ansesthetizing  room;  (4)  on  the  operating  table  in  the 
operating  room.  Two  considerations  should  influence  our 
decision:  (a)  The  patient  should  not  be  moved  after  the 
anesthetic  is  begun;  {h)  the  patient  should  be  spared  that 
which  will  cause  anxiety:  i.e.,  the  sight  of  instruments. 
In  the  home  the  anesthetic  should  invariably  be  induced 


COMPLETE  GENERAL  ANESTHESIA  19 

upon  the  bed  or  tiible  where  the  operation  is  to  take  plaee. 

In  the  liospital,  the  anaesthetic  should  be  induced  on  the 
operating  table  in  the  ana'sthetizing  room. 

If  this  be  impossible,  choose  the  lesser  evil  of  frighten- 
ing the  patient  and  induce  the  anaesthesia  in  the  operating 
room  upon  the  operating  table.  IVIost  patients  are  not 
frightened,  however,  if  the  circumstances  are  explained 
before  hand. 

Patients,  who  are  not  moved  after  the  anaesthetic  has 
commenced,  usually  have  a  smoother  induction.  They  may 
be  scrubl)ed  up  upon  the  first  signs  of  relaxation  and  it  is 
Qot  necessary  to  lift  their  dead  weight. 

The  indirect  control  of  the  period  of  excitement  may 
therefore  be,  summarized  as  follows : 

(  For  suggestive  therapeutics. 

Preliminary  visit "j  Examination:     History,    heart,    lungs, 

(       urine  and  teeth. 

i  General  diet  with  candy. 
Sleep,  with  veronal  if  necessary. 
Preliminary  morphine  where  not  con- 
traindicated. 

( On   operating   table    in    anaesthetizing 

Place  of  anaesthesia s       room. 

t  On  operating  table  in  operating  room. 

llie  Direct  Control  of  the  Period  of  Ecccitement. — The 
direct  control  of  the  period  of  excitement  may  be  described 
as  that  control  which  we  exert  after  the  patient  has  reached 
the  place  of  operation. 

If  the  indirect  control  has  been  conscientiously  carried 
out,  i.e.,  if  the  patient  has  received  a  preliminary  visit,  the 
confidence  won,  a  good  night's  rest  secured  and  prelimi- 
nary morphine  received,  the  period  of  excitement  will  be 
conspicuous  by  its  absence. 


20  ANAESTHESIA 

This  ideal,  however,  is  not  always  obtained  in  private 
work  and  seldom  in  the  hospital,  where  the  anesthetist 
often  meets  the  patient  for  the  first  time  in  the  anfesthetiz- 
ing  room,  lying  on  a  stretcher  swaddled  in  ))lankets  and 
strapped  to  a  frame.  The  alcoholic,  the  inveterate  smoker, 
crying  children,  hysterical  women,  and  those  who  fail  to 
miderstand  what  anaesthesia  means  are  placed  before  him 
without  any  effort  having  been  made  to  investigate  their 
various  needs.  The  treatment  of  these  intrinsic  causes 
of  excitement  resolves  itself  into  a  sympathetic  attitude  on 
the  part  of  the  anaesthetist.  He  may  exjDress  this  by  his 
manner  of  ajjproach,  his  touch,  and  his  tone  of  voice.  It 
is  never  too  late  to  inquire  into  urine  analysis,  false  teeth, 
chewing  gum,  previous  anaesthetization,  etc.  The  patient 
should  be  instructed  to  hold  his  breath.  If  he  cannot  do  so 
for  a  period  of,  at  least,  30  seconds,  acidosis  or  poor  car- 
diac compensation  may  be  suspected.  The  extrinsic  causes 
of  excitement  may,  however,  be  more  directly  controlled. 

The  normal  reflexes  of  the  pharynx  and  larynx  are  to 
be  abolished.  These  membranes  must  be  rendered  insen- 
sitive to  any  concentration  of  ether  vapor.  In  the  presence 
of  these  reflexes,  the  patient  will  not  be  ansesthetized.  Vapor 
which  is  intolerable  to  these  membranes  in  their  normal 
state  is  of  insufficient  strength  to  put  the  patient  to  sleep. 

We  may  abolish  these  reflexes  by  coaxing  or  by  driv- 
ing them  to  sleep. 

Coaxing  should  always  be  the  method  of  choice. 

This  is  best  accomplished  by  the  employment  of  the 
drop  method.  If  the  open  drop  method  is  employed,  invite 
the  patient  to  count  slowly  and  loudly;  or  if  a  child,  to 
blow  the  smell  away.  If  the  patient  holds  the  breath  or 
coughs,  stop  until  the  breathing  is  once  more  regular ;  then 
start  again  and  increase  as  rapidly  as  the  tolerance  will 


COMPLETE  GENERAL  AN^ESTHESLV  ^21 

permit.  The  point  will  soon  be  reached  where  the  maxiniuni 
amount  (as  much  as  can  be  vaporized)  is  being  given.  It 
is  only  a  question  of  a  few  moments  then  to  the  completion 
of  induction. 

Driving  the  reflexes  to  sleep. 

Some  patients  exhil)it  an  abnormal  degree  of  sensitive- 
ness to  ether  vapor.  If  it  is  found  that  even  diluted  vapor 
cannot  be  tolerated,  the  following  must  be  considered:  In 
the  normal  case  the  necessity  to  breathe  or  the  "  Besoin  de 
respire  "  overcomes  whatever  inhibition  may  exist  by  rea- 
son of  the  slightly  irritating  effect  of  the  ether  vapor.  In 
the  abnormal  case  in  question  the  inhibition  is  not  overcome 
by  the  "  Besoin  de  respire."    Our  indications  are  therefore: 

1.  To  increase  the  necessity  for  breathing.* 

2.  To  abolish  the  reflexes  by  shocking  them  through  the 
use  of  very  concentrated  ether  vapor. 

The  first  is  accomplished  by  using  an  air-tight  appara- 
tus which  limits  oxygenation,  and  by  rebreathing  aff"ords 
the  stimulating  CO-. 

The  second  is  accomplished  by  having  convenient  means 
whereby  the  concentration  of  the  ether  vapor  used  may  be 
rapidly  increased. 

The  patient  must  breathe,  and  in  doing  so  quickly  para- 
lyzes the  membranes,  thereby  doing  away  with  the  cause 
of  the  inhibited  respiration. 

Should  this  treatment  result  in  severe  spasm  and  cyano- 
sis, it  must  be  temporarily  abandoned  and  the  patient  given 
fresh  air.  As  soon  as  breathing  is  again  resumed  the  mask 
is  reapplied. 

There  is  no  use  in  pouring  ether  at  a  patient,  nclio  is  not 
breathing. 

After  the  mucous  membranes  have  lost  their  sensitive- 
ness, careful  administration  of  a  vapor  moderately  concen- 


22  ANAESTHESIA 

trated  will  avoid  spasm  of  the  larynx,  which  may  otherwise 
occur. 

AVhen  NoO  is  used  for  induction  ether  should  be  given 
without  removing  the  apparatus  from  the  face.  The  CO2 
of  the  respirations  collecting  in  the  apparatus  deepen  the 
respirations  ( see  page  299 ) .  The  deeper  and  freer  the  res- 
pirations, the  easier  it  is  to  saturate  the  circulation  with  ether. 

The  direct  control  of  the  excitement  demands  the  pres- 
ence of  one  or  more  assistants.  Someone  besides  the  anaes- 
thetist should  not  only  be  present  but  unsterile.  When  the 
patient  is  on  a  stretcher,  linen  bandages  or  special  restrain- 
ing straps  are  used.  Upon  a  bed,  sheets  or  blankets  may 
be  employed. 

The  following  is  a  case  in  which  the  anaesthetist  "  took  a 
chance,"  and  started  anaesthetizing  the  patient  without  as- 
sistance at  hand.  The  surgeon  and  nurse  were  "  scrubbing 
up  "  in  another  room.  The  patient  lay  across  the  bed  un- 
restrained, in  preparation  for  an  obstetrical  operation. 
The  induction  progressed  with  perfect  smoothness  until  all 
at  once  the  patient  developed  sharp  excitement.  She 
laughed,  threw  her  hands  over  her  head,  and  tore  off  the 
face  piece.  She  drew  up  her  knees  and  writhed  about, 
winding  up  in  an  inaccessible  position  parallel  with  the  bed. 
She  was  with  difficulty  pulled  back  into  place  and  the  face 
2)iece  reapplied.  A  moment  later  the  bed  spring  gave  way 
at  the  head  of  the  bed  and  the  patient  slid  into  a  hole, 
from  which  she  was  finally  extricated  before  consciousness 
returned.  After  the  operation  she  awoke  quickly,  without 
sickness  and  grateful  for  a  delightful  anasthesia. 

Insist  on  having  complete  control  of  the  patient's  head. 

The  author  recalls  a  case  in  which  he  failed  to  insist 
upon  this  arrangement.  The  operation  was  for  paracente- 
sis of  the  ear  drum,  complicated  by  a  valvular  lesion  and 


COMPLETE  GENERAL  ANAESTHESIA  23 

poor  compensation.  Proper  extension  of  the  head  was  not 
obtained.  Respiratory  obstruction  resulted,  and  when  the 
ana?sthesia  was  stopped  the  patient  suffered  from  grave 
cardiac  dyspnoea  (see  Fig.  11,  illustrating  the  correct  and 
Fig.  12,  the  incorrect  control  of  the  head). 

The  sense  of  hearing  persists  after  the  loss  of  smell, 
taste,  sight,  and  touch.  This  is  particularly  true  when 
nitrous  oxide  is  used.  A  short  time  ago  a  patient  was 
anesthetized  with  nitrous  oxide  and  oxygen.  When  almost 
ready  for  operation,  the  surgeon  said  to  the  anaesthetist: 
"  Let  me  know  when  you  are  ready."  A  few  moments 
later  the  operation  was  performed,  the  anesthesia  being 
perfectly  satisfactory.  L^pon  recovery  the  patient  re- 
ported that  the  last  thing  she  knew  was  Dr. remarking: 

"  Let  me  know  when  you  are  ready." 

One  should  be  careful  not  to  make  any  remark  which 
may  be  remembered  by  the  patient,  or  possibly  arouse  a 
subconscious  fear. 

The  direct  control  of  the  period  of  excitement  may 
therefore  be  summarized  as  follows: 

1.  By  the  concentration  of  the  anaesthetic. 

2.  By  assistance  to  help  restrain  the  patient. 

3.  By  the  use  of  NoO  and  a  close  apparatus  for  induction. 

4.  By  the  proper  control  of  the  patient's  head. 

5.  By  quiet  in  the  anaesthetizing  room. 

The  Second  Period  of  Induction  :  Rigidity 
Taking  up  the  second  period  of  induction,  rigiditij,  we 
shall  consider  its  evidences,  causes  and  control. 

A.  Ea^idences  of  Rigidity.— Rigidity  may  be  seen  in 

all  classes  of  muscles,  in  voluntary  as  well  as  in  involuntary 

muscles.     We  may  conveniently  divide  these  classes  into: 

{a)   Those  muscles  which  usually  act  under  the  direct 


24 


ANESTHESIA 


Fig.  II. — Correct  control  of  the  head,  the  patient  across  the  bed. 


Fig.  12. — Incorrect  control  of  the  head,  the  patient  parallel  with  the  bed. 


COMPLETE  GENERAL  AN.ESTHESL^  25 

control  of  the  will,  i.e.,  the  muscles  of  the  arms,  legs,  mas- 
seters. 

(b)  Those  muscles  which  usually  act  reflexly,  i.e.,  the 
sphincter  nuiscles,  respiratory  nuiscles,  uterine  muscles. 

Graphically  we  may  describe  the  patient  who  is  rigid 
as  follows: 

The  arms  and  legs  tend  to  flex,  the  fingers  are  clenched, 
the  muscles  of  the  neck  resist  the  effort  on  the  part  of  the 
anaesthetist  to  turn  the  head  to  the  side.  The  teeth  are 
tighth'  closed,  and  it  will  be  found  that  the  lower  jaw,  when 
grasped,  cannot  be  made  to  open  freely.  The  respiration 
is  usually  obstructed  and  the  accessory  muscles  of  respira- 
tion stand  out  hard  and  prominently.  The  eyelids  are 
tightly  shut.  The  breathing  is  thoracic,  the  abdominal 
muscles,  in  vigorous  subjects,  showing  clearly  beneath  the 
skin,  tense  and  board-like.  These  signs  may  appear  to- 
gether or  separately. 

Pseudo-rigidity,  or  rigidity  due  to  faulty  position,  ab- 
dominal distention  and  unusually  w-ell-developed  muscu- 
lature, occasionally  occurs.  This  should  be  recognized 
and  differentiated  from  the  rigidity  which  is  due  to  incom- 
plete anaesthesia. 

Causes  of  Rigidity 

1.  Prolonged  Excitement  from  any  Cause. — The  ner- 
vous mechanism,  whose  activity  gave  rise  to  the  stage  of 
excitement,  is  the  same  power  which  furnishes  the  stimuli 
for  muscular  contractions. 

Rigidity  is  the  tonic  or  tetanic  contraction  of  muscle  as 
a  result  of  continuous  stimuli.  We  see  these  stimuli  in  the 
early  stages  of  excitement  resulting  in  voluntary  and 
occasional  movements.  Later  the  stimuli  increase,  be- 
come more  frequent  and  of  a  clonic  nature,  conveniently 


26  ANiESTHESIA 

spoken  of  as  muscular  excitement.  Lastly  we  see  the  effect 
of  an  overwhelming  flow  of  stimuli,  giving  rise  to  an  appar- 
ently continuous  contraction  and  resulting  in  what  we 
term  rigidity.  This  summation  of  stimuli  not  only  causes 
the  muscle  to  contract  but  also  to  become  actually  shorter. 

When  we  realize  this  hardening  and  shortening  of  the 
rigid  nmscle,  particularly  in  the  case  of  the  abdominal  mus- 
cles, we  will  easily  understand  how  rigidity  may  interfere 
with  intra-abdominal  manipulations. 

2.  Obstructed  Respiration. — Obstructed  respiration  is 
one  of  the  most  constant  causes  of  muscular  rigidity  for,  by 
decreasing  the  tidal  volume  of  the  res^^ired  air,  it  prevents 
us  from  introducing  the  proper  quantity  of  the  angesthetic 
into  the  circulation.  The  circulation  must  be  saturated 
with  ether  to  the  extent  of  1  to  400  parts  or  at  a  vapor  ten- 
sion of  48  mm.  (see  page  64),  before  the  full  effect  of  the 
aneesthetic  is  obtained.  In  addition  to  this,  a  lack  of  suffici- 
ent oxygen  j^^f  se  is  frequently  the  cause  of  rigidity. 

If  the  progressive  increase  is  interfered  with  at  the  time 
of  induction,  the  an^esthetization  is  not  only  delayed  but 
almost  immediately  becomes  lighter,  and  in  the  presence  of 
this  lighter  stage,  vomiting  and  muscular  rigidity  often 
suj^ervene.  Induction  must  constantly  progress  to  the 
stage  of  maintenance,  if  the  best  results  are  to  be  secured. 

We  may  conveniently  consider  obstruction  to  the  res- 
piration as  occurring: 

(«)    Outside  the  respiratory  system. 

{h)  In  that  portion  bounded  externally  by  the  nares 
and  lips,  internally  by  the  epiglottis. 

{c)    From  the  epiglottis  to  the  bronchi. 

{d)    From  the  bronchi  to  the  alveoli. 

{a)  Among  the  most  common  forms  of  obstruction  to 
respiration  occurring  outside  of  the  respiratory  tract  are: 


COMPLETE  GENERAL  AN.ESTHESLV  27 

Improper  apparatus  with  a  restricted  airway.  The  res- 
pirations should  not  be  obliged  to  pass  through  a  tube 
whose  area  is  less  than  the  trachea,  or  about  y^  of  an  inch. 
This  is  particularly  true  during  the  stage  of  induction, 
when  the  respirations  are  increased  in  rapidity  and  volume. 
It  will  often  be  found  that,  even  when  the  airway  is  free 
[before  it  is  packed  with  gauze]  after  this  has  been  placed 
in  situ,  tliis  airway  becomes  very  much  restricted. 

External  pressure  should  be  avoided.  Dressings  placed 
in  preparation  for  neck  operations  should  be  loose.  Too 
tight  strapping  of  the  patient  or  the  weight  of  assistants 
on  the  neck  or  chest  will  naturally  obstruct  the  respiration. 

Intra-abdominal  growths  or  fluid,  by  pressing  against 
the  diaphragm,  may  seriously  affect  the  breathing. 

Within  the  respiratory  tract,  but  external  to  the  airway 
proper,  pleurisy  with  effusion,  empyema  and  enlarged 
bronchial  glands  frequently  form  complications,  which 
must  be  thoughtfully  dealt  with. 

The  position  of  the  patient,  Trendelenburg  for  pelvic 
work,  prone  for  operations  on  the  coccyx,  all  more  or  less 
embarrass  the  respiration.  It  is  surprising,  however,  how 
well  patients  do  in  spite  of  the  embarrassment,  which  their 
positions  might  suggest.  The  habitual  semiprone  or  prone 
position  in  natural  sleep  may  perhaps  be  accountable  for 
the  unexj^ected  successes  which  we  meet  in  these  cases. 

[b)  Obstruction  occurring  bctvccen  the  lips,  nares  and 
epiglottis.  Obstruction  to  the  respiration,  which  cannot  be 
accounted  for  through  external  embarrassment,  will  usu- 
ally be  traced  to  obstruction  in  this  location,  as  from  ade- 
noids, polypi,  deviated  septum,  enlarged  turbinates  and 
paralyzed  soft  palate,  which  obstruct  the  nasal  respiration. 

Oral  obstruction  may  occur  through  teeth  which  coapt 


28  ANiESTHESLV 

perfectly  upon  themselves,  or  which  are  closed  in  spasm  on 
the  tip  of  the  tongue.  The  lips  of  toothless  persons,  which 
flap  valvelike  to  and  fro  without  admitting  air,  paralysis 
of  the  tongue,  which  causes  it  to  drop  back  into  the  pharynx 
and  enlarged  f  aucial  tonsils  may  also  cause  obstruction. 

(c)  Obstruction  occurring  from  the  epiglottis  to  the 
bronchi.  Obstruction  here  may  be  caused  by  oedema  of  the 
glottis,  spasm  of  the  vocal  cords,  giving  rise  to  crowing 
respiration,  external  pressure  of  glands  or  goitre,  mucous 
or  vomited  material  inspired. 

{d)  Obstruction  occurring  below  the  bronchi.  This  is 
caused  by  anything  which  involves  the  alveoli,  as  for  exam- 
ple, pulmonary  tuberculosis,  ^^neumonia,  asthma,  bron- 
chitis, bronchiectasis  or  abscess  of  the  lung.  This  type  of 
obstruction  will  become  evident  by  the  fact  that  even  with 
the  oral  and  laryngeal  respiration  free  and  no  cardiac  in- 
sufficiency having  been  found,  yet  the  patient  tends  to 
persistent  cyanosis. 

3.  Operations  Begun  Before  the  Skin  Reflexes  are 
Abolished. — This  procedure,  by  sending  a  flood  of  sensory 
impulses  to  the  cord  and  higher  centres,  may  give  rise  to  a 
reflex  which  results  in  tetanic  muscular  contractions  or 
rigidity.  This  rigidity  may  be  local  or  general,  involving 
the  general  musculature  or  limited  to  the  painful  locality. 

•1.  Dilation  of  the  Sphincters. — Even  after  anaesthesia 
has  been  w^ell  induced  and  satisfactory  relaxation  obtained, 
the  dilation  of  the  anal  sphincter  of  primiparous  cervix 
may  give  rise  to  stimuli,  which  are  sufficient  to  send  motor 
impulses  along  those  nerves  whose  normal  irritability  has 
been  hitherto  lowered  by  the  influence  of  the  anaesthetic. 

Upon  the  cessation  of  this  profound  stimulation,  the 
patient  will  be  found  to  be  in  a  satisfactory  anaesthetic 


COMPLETE  GENER.\L  ANESTHESIA  29 

state.  If  the  amount  of  the  anaesthetic  has  been  increased 
so  as  to  totally  abolish  all  effects  of  this  stimulation,  when 
the  dilation  has  been  accomplished,  the  patient  will  be 
found  to  be  unnecessarily  "  deep."  Therefore,  as  long  as 
these  reflexes  do  not  interfere  with  the  surgeon,  they  may 
be  permitted  to  persist. 

5.  Manipidaiions  in  the  Region  of  the  Pelvis  or  Gall- 
Bladder. — In  presence  of  a  moderately  deep  anjesthesia, 
reflexes  from  these  sources  may,  by  increasing  the  depth  or 
possibly  obstructing  the  respirations,  produce  transient 
rigidity.     Relaxation  usually  follows  upon  their  cessation. 

6.  Faulty  Position  of  the  Patient. — Pseudo-rigidity,  or 
apparent  rigidity,  may  appear  where  an  improper  position 
of  the  patient  obtains.  This  is  frequently  the  case  where 
the  desired  j^osition  has  not  been  completely  obtained. 
Operation  upon  the  neck,  gall-bladder,  kidney,  coccyx  and 
female  pelvic  organs  occasion  most  of  these  embarrassments. 

7.  Operation  in  the  Upper  Abdomen  Per  Se. — Com- 
plete relaxation  in  operations  involving  an  incision  through 
the  upper  abdomen  is,  as  a  rule,  difficult  to  obtain.  Thus, 
operations  upon  the  stomach,  pancreas,  liver,  spleen,  etc., 
imply  a  profound  anaesthesia,  and  special  attention  to  the 
position  and  the  respiration  of  the  patient. 

8.  Distention  of  the  Abdomen. — In  this  case  a  pseudo- 
rigidity  is  likely  to  be  seen  when  the  closure  of  the  wound 
is  being  done,  the  operation  in  itself  having  failed  to  relieve 
the  distention,  i.e.,  an  operation  for  intestinal  obstruction 
in  obese  patients. 

9.  The  Anaesthetic  Used. — A  certain  degree  of  rigidity 
is  quite  constantly  to  be  expected  when  the  anaesthetic  is 
nitrous  oxide  and  occygen.  This  holds  good  even  during 
a  stage  of  satisfactory''  maintenance. 


so  ANESTHESIA 

We  may  then  sumniarize  the  causes  of  rigidity  as  fol- 
lows: (1)  Excitement;  (2)  obstruction  to  the  respiration.; 
(3)  operations  begun  too  early;  (4)  sphincter  dilatation; 
(5)  gall-bladder  and  pelvic  manipulations;  (6)  faulty 
position;  (7)  operations  on  upper  abdomen ;  (8)  distention 
of  the  abdomen ;  ( 9 )  the  ty^^e  of  anaesthetic  used. 

Further  Explanatory  Xotes  ox  Rigidity. — The 
evidences  of  rigidity  having  become  apparent  and  the  im- 
mediate causes  enumerated,  it  may  not  be  amiss  to  consider 
briefly  its  deeper  meaning  as  expounded  by  G.  W.  Crile 
of  Cleveland. 

This  investigator's  altogether  fascinating  theories  on 
shock  will  serve  to  throw  some  light  upon  the  phenomena 
of  that  rigidity  due  to  the  pain  of  the  first  incision  and  the 
subsequent  rigidity  arising  from  reflex  stimulation,  such  as 
dilation  of  the  sphincters,  manipulations  about  the  gall- 
bladder or  in  the  pelvis. 

According  to  Crile,  among  the  most  highly  developed 
reflexes  are  those  which  respond  to  pain  stimuli.  In  the 
normal  man,  to  inflict  physical  pain  is  to  imply  a  muscular 
reaction,  an  expression  of  reflex  self-defense.  For  exam- 
ple, if  the  finger  were  cut  or  burned,  the  hand  would  imme- 
diately be  withdrawn.  AMien  the  skin  of  the  abdomen  is 
cut  or  when  the  peritoneum  is  irritated,  the  abdominal  mus- 
cles become  board-like.  This  rigidity  comes  about  appar- 
ently for  the  purpose  of  protecting  the  deeper  structures. 

Crile  maintains  that  anaesthesia  does  not  prevent  the 
flow  of  afferent  or  pain  sensations  to  the  cord  and  brain. 

What  the  ana?sthetic  does  do  to  a  greater  or  less  extent 
is  to  interfere  with  the  motor  power  of  the  muscles  nor- 
mally included  in  this  reflex. 

If  the  pain  stimuli  of  an  early  incision  reach  the  cord 


COMPLETE  GENERAL  AX/ESTHESIA  31 

before  the  motor  portion  of  the  reflex  arc  has  been  com- 
pletely obliterated  by  the  ana'stlietic,  the  result  will  be  the 
contraction  of  those  muscles  normally  affected  by  this  re- 
flex, and  rig'idity  will  result.  Dilaticm  of  the  sphincters 
gives  rise  to  pain  and  results  not  only  in  muscular  rigidity, 
but  acts  more  deeply  by  affecting  the  respiration  and  more 
rarely  the  pulse. 

Since  anaesthesia  does  not  abolish  the  effects  of  actual 
pain  upon  the  nervous  system,  the  profound  exhaustion 
and  shock,  which  one  would  expect  in  the  case  of  a  pro- 
longed operation  without  an  ana?sthetic,  also  obtains  in  all 
operations  with  anjesthesia,  the  difference  in  the  two  cases 
being  that  with  the  anaesthetic  the  patient  is  spared  the  con- 
scious pain  and  unpleasant  memories. 

Whether  or  not,  and  to  what  degree  the  pain  impulses 
to  the  cord  and  brain  are  affected  by  the  anaesthetic  is  still 
a  matter  for  discussion.  We  may  safely  conclude,  how- 
ever, that  all  irritability  is  not  subdued,  for  manipulations 
about  large  nerve  centres  and  undue  roughness  on  the  part 
of  the  surgeon  will  frequently  cause  shock  even  in  the  face 
of  a  brief  and  profound  amesthesia.  The  significance  of 
rigidity  associated  with  pain  stimuli  and  its  disappearance 
in  the  face  of  deeper  antesthetization  is  not,  therefore,  a 
license  to  unnecessarily  damage  or  destroy  tissue. 

If  Crile's  premises  are  true,  profound  anaesthesia  is  like 
obscuring  abdominal  pain  by  the  use  of  mor23liine.  It 
covers  over  but  does  not  remove  or  cure  the  underlying  con- 
dition, which  in  this  case  is  not  disease  but  surgical  tramna. 

Local  anaesthesia  does  prevent  afferent  stimuli  or  pain 
impulses  to  the  cord  or  brain.  If  all  necessary  manipula- 
tions are  done  under  cover  of  this  nerve  blocking,  as  is 
Crile's  constant  technic,  and  if  all  unnecessary  trauma  is 


32  ANAESTHESIA 

avoided,  then  a  light  antesthesia  becomes  not  only  the 
method  of  choice  but  enables  the  surgeon  to  detect  pain, 
which  he  may  unwittingly  occasion  and  desire  to  avoid. 

Rigidity  then  may  have  a  deeper  significance  than 
would  appear  upon  a  superficial  consideration.  When 
caused  by  pain,  it  is  more  than  a  mere  mechanical  embar- 
rassment. It  is  a  crying  out  on  the  part  of  the  organism 
against  the  trauma  which  is  being  inflicted  upon  delicate 
and  sensitive  tissues.  We  deepen  the  anaesthesia  and  figu- 
ratively choke  off  this  sign  of  the  patient's  resistance. 
The  result,  according  to  Crile,  is  the  creation  of  an  illusory 
protection,  which  in  all  likelihood  the  nervous  system  of  the 
patient  does  not  experience. 

C.  The  Control  of  the  Period  of  Rigidity. — We 
have  seen  what  evidences  of  rigidity  we  may  expect.  We 
have  considered  the  most  important  causes  of  the  condition. 
To  imply  the  method  of  the  removal  of  these  causes  is  not 
sufficient ;  we  must  patiently  consider  in  detail  the  methods 
we  will  use  to  arrive  at  the  desired  end.  The  proper  control 
of  rigidity  will  tax  the  art  of  the  anaesthetist  to  the  utmost. 

1.  Since  ea'citement  is  one  of  the  most  common  causes 
of  rigidity,  it  may  not  be  amiss  to  recall  the  control  which 
was  suggested  for  this  stage,  namely : 

r  For  symptoms. 
Preliminary  visit.  -It-*  ^ 

(  J^or  suggestive  therapeutics. 

Indirect  ^  ^  Diet. 

Sleep. 
Preliminary  medication.  \  Preliminary  morphine. 

Beginning  the  anaesthetic  on  the 
operating  table. 


COMPLETE  GENER.\L  ANAESTHESIA  33 

'  Concentration  i  Dilute  for  coaxing, 
of  I  Concentrated  for 

anaesthetic.        *■      driving. 

Direct i   Attendants  for  restraining. 

Control  of  the  head. 

Use  of  X2O  and  close  aj)i)aratu.s. 

Quiet  in  anaesthetizing  room. 

2.  The  Control  of  Obstruction  to  the  Respiration. — 
The  obstruction  which  is  due  to  occhision  of  the  nasal  air- 
way may  be  ignored  by  providing  satisfactory  respiration 
through  the  mouth. 

When  the  teeth  are  clenched,  causing  an  obstruction 
which  results  in  cyanosis  and  light  ana?sthesia,  they  must  be 
separated  or  air  otherwise  introduced  to  relieve  the  spasm. 
It  will  be  found  that  there  is  often  a  space  between  the  last 
molar  and  the  jaw.  The  finger  may  be  introduced  here  and 
the  tongue  depressed.  Occasionally  a  tooth  is  missing, 
which  leaves  a  space  for  the  introduction  of  the  mouth  gag 
or  finger.  One  should  be  careful  to  protect  the  finger,  other- 
wise a  serious  bite  resulting  in  a  septic  wound  may  result. 

A  large  catheter  passed  into  the  pharynx  through  one 
of  the  nostrils  will,  b}'  admitting  air,  often  relieve  the  spasm. 

Finally,  the  teeth  should  be  separated  and  a  throat  tube 
introduced.  The  best  thing  for  this  purpose  is  a  boxwood 
wedge  and  tube,  as  shown  in  Figs.  13  and  14. 

The  teeth  are  gently  separated  by  the  sharp  edge  of  the 
wooden  wedge.  When  sufficient  space  has  been  secured, 
the  tube  may  be  slipped  into  the  mouth  over  the  \.o\)  of  the 
tongue  (Fig.  15).  An  adequate  airway  will  thereby  be 
immediately  secured  and  the  spasm  and  rigidity  will  j^ass 
off.  It  is  impossible  to  laud  too  highly  this  tube,  which  may 
be  called  the  "  Sine  qua  non  "  of  the  amesthetist. 
3 


34 


ANAESTHESIA 


Obstruction  between  the  epiglottis  and  the  bronchi. 
fEdeiiia  of  the  glottis,  secondary  to  burns  or  inspiration  of 
liquid  ether,  must  be  dealt  with  vigorously.  Diagnosis  of 
this  condition  is  made  by  excluding  nasal  obstruction, 
laryngeal  spasm,  and  a  history,  which  might  lead  one  to 
suspect  obstruction  below  the  epiglottis.  One  of  two  things 


Fig.   13. — The  boxwood  mouth  wedge. 

must  be  done — intratracheal  intubation  or  tracheotomy. 
Spasm  of  the  vocal  cords  is  a  peculiar  and  annoying 
type  of  obstruction.  Its  causation  is  obscure  and  its  relief 
often  difficult.  A  hurried  induction  hampered  by  obstruc- 
tion is  often  its  precursor.  Occasionally  it  follows  an  inci- 
sion which  has  been  made  too  early.  A  change  of  the  anaes- 
thetic state  to  shallowness  when  the  patient  is  deep,  or 


Fig.    14. — -The  author's  modification  of  the  Connell  throat  tube. 

deeper  when  the  ana3sthesia  is  slight,  is  often  beneficial. 
Strange  as  it  may  seem,  if  in  the  course  of  a  comjDaratively 
deep  ana?sthesia  with  persistent  crowing  respirations, 
pelvic,  gall-bladder  or  other  deep  reflex  be  stimulated,  the 
crowing  will  lessen  and  often  disappear.  The  attention  of 
the  nervous  system  has  been  distracted,  so  to  speak.  Rhyth- 
mical traction  of  the  tongue  may  relieve  this  disturbance. 
Mucus,  saliva  and  vomited  material  may  be  drained  by 


COMPLETE  GENERAL  ANESTHESIA  35 

the  use  of  the  Trendelenl)iirg  position  or  by  the  sucker, 
commonly  found  in  the  operating  room  (see  page  323). 
Or  the  pliaryngeal  reflexes  may  be  permitted  to  return 
and  expel  the  foreign  material.  The  jDreliminary  use  of 
morphine  and  atropine,  by  reducing  the  secretion  and 
the  irritability  of  the  pharyngeal  nuicous  membranes, 
often  acts  as  a  prophylactic  against  this  type  of  obstruction. 

Obstruction  due  to  glands 
and  goitres  must  be  dealt 
with  in  such  a  way  that  the 
period  of  ecccitement  will  be 
reduced  to  a  minimum.  Any- 
thing which  tends  to  increase 
blood-pressure  at  the  induc- 
tign  must  be  avoided,  as  for 
example,  the  use  of  nitrous 
oxide  without  oocygen,  or 
pushing  the  concentration 
before  the  patient  is  deeply 
enough  "  under  "  to  accept  it. 
The  control  of  the  obstruc- 
tion    occurring     below     the 

7  J  •        r^\      I  I  •  1 ,  Fig.   15. — Throat  tube  in  place. 

bronchi.     Obstruction  result- 
ing  from   pneumonia,    asthma,   etc.,    should   be   met    by 
employing  oxygen  with  the  ether  administration. 

3.  Rigidity,  which  is  caused  by  an  incision  made  before 
satisfactory  induction  has  taken  place,  will  usually  dis- 
appear on  deepening  of  the  anaesthesia.  L^nless  occurring 
during  consciousness,  or  associated  with  respiratory  ob- 
struction, it  need  cause  no  alarm,  if  ether  is  the  anaesthetic. 

4.  Rigidity  during  the  dilation  of  the  sphincters,  unless 
interfering  with  the  surgeon,  may  well  be  permitted;  for 


36  ANESTHESIA 

this  usually  gives  place  to  relaxation,  when  the  excessive 
reflex  has  ceased. 

5.  Transient  rigidity,  which  occurs  during  pelvic  and 
gall-hladder  vcorh,  must  be  temporarily  abolished,  if  it 
jjroves  inconvenient  to  the  surgeon.  AMien  these  manipu- 
lations have  been  completed,  the  j^atient  may  be  permitted 
to  "  come  out "  somewhat.  The  important  point  to  be  borne 
in  mind  is  that  the  patient  is  not  necessarily  light  if  he  shows 
some  disturbance  in  the  face  of  these  profound  reflexes. 

6.  The  position  of  the  patient  is  such  an  important  fac- 
tor in  producing  rigidity  that  it  seems  wise  to  illustrate 
comjjrehensively  the  positions  most  used.     (Figs.  16-45). 

The  Trendelenburg  Posture  (Figs.  16,  17,  18,  19, 
20). — The  Trendelenburg  jDOsture  is  one  in  which  the  pa- 
tient lies  on  the  back  on  a  plane  inclined  about  45  per  cent., 
the  feet  and  legs  elevated  hanging  over  the  edge  of  the 
table,  the  weight  of  the  body  supported  by  shoulder  braces. 
Table  set  for  Trendelenburg  position  is  shown  in  Fig.  16. 

The  patient  is  first  placed  in  the  dorsal  position  upon 
the  horizontal  table.  The  knees  are  so  placed  in  relation 
to  the  break  in  the  foot  of  the  table,  that  when  the  latter 
is  dropped,  the  legs  will  be  parallel  to  this  portion.  If  the 
patient  is  not  sufficiently  near  the  end  when  the  foot  of 
the  table  is  dropped,  the  knees  will  not  be  properly  flexed 
and  the  feet  will  stick  up  in  the  air.  If,  on  the  other  hand, 
the  patient  is  too  far  down  when  the  table  is  broken,  she 
will  not  receive  the  proper  support,  for  in  this  case  she  will 
rest  entirely  upon  the  shoulder  braces.  The  patient  should 
be  pulled  down  toward  the  foot  of  the  horizontal  table 
until  the  break  is  about  oj^posite  the  junction  of  the  middle 
and  lower  third  of  the  thigh.  If  the  patient's  calves  are 
thick  and  muscular  the  distance  should  be  greater  than  if 
they  be  emaciated  and  relaxed. 


COMPLETE  GENERAL  AN.ESTHESL\  37 

When  the  knees  are  properly  placed  in  relation  to  the 
break  in  the  table  (Fig.  17),  the  arms  are  extended, 
brought  close  to  the  patient's  sides  and  the  hands  witli  the 
fingers  extended  are  placed  out  of  sight  under  the  buttocks. 

The  shoulder  braces  are  next  placed  in  position. 
They  should  invariably  be  used.  Where  the  patient  is 
obliged  to  support  her  weight  by  her  knees,  she  is  liable  to 
develop  paralysis  by  pressure  u^^on  the  peroneal  nerve. 

With  the  knees  properly  placed,  the  hands  under  the 
patient  and  the  shoulder  braces  in  place,  the  table  is  ele- 
vated and  the  feet  are  dropped.  The  position  shown  in 
Fig.  18  then  obtains. 

Some  operators  believe  that  better  abdominal  relaxa- 
tion results  if  the  knees  are  not  flexed,  as  shown  in  Figs. 
19  and  20. 

The  object  of  the  Trendelenburg  position  is  to  secure 
better  exjjosure  of  the  pelvic  organs  by  virtue  of  the  dis- 
placement by  gravity  of  the  abdominal  viscera.  It  is  most 
advantageoush^  used  in  thin  subjects.  It  is  contraindicated 
in  cases  presenting  free  pelvic  pus.  This  position  pro- 
duces engorgement  of  the  blood  vessels  of  the  head  and 
neck.  The  pharyngeal  structures  and  the  tongue  are 
swollen  and  often  give  rise  to  obstructed  respiration. 
Where  there  is  danger  of  acute  cardiac  dilatation  through 
a  preceding  acute  infection  or  fatty  degeneration,  this  posi- 
tion should  not  be  used  because  of  the  increased  strain 
thrown  on  the  right  heart. 

In  fat  people  the  use  of  this  position  has  been  followed 
by  intestinal  obstruction.  Volvulus  of  the  ilemn  and  of 
the  large  intestine  have  also  occurred.  When  the  Trendel- 
enburg position  has  been  employed,  the  omentum  should  be 
spread  out  in  its  normal  position  after  the  table  is  raised. 


38 


ANAESTHESIA 


Fig.   16. — Table  in  Trendelenburg  position. 


Fig.   17. — Patient  ready  for  Trendelenburg  position. 


COMPLETE  GENERAL  AN.ESTHESL\  39 


Fig.    18. — Patient  in  Trendelenburg  position. 


FiQ.  19. — Table  in  position  for  Trendelenburg  position — feet  straight. 


40  ANAESTHESIA 

On  the  other  hand  this  position  presents  many  distinct 
advantages.  It  is  the  safest  in  which  to  administer  chloro- 
form. Mucous  and  sahva  which  have  collected  in  the 
pharynx  drain  off  by  gravity.  In  very  sick  cases  the  cere- 
bral circulation  is  thus  best  maintained.  Patients,  who 
have  been  carried  upon  a  comparatively  light  anaesthesia 
in  the  horizontal  jiosition,  frequently  "  come  out "  somewhat 
when  the  head  is  lowered.    The  converse  is  also  true. 

The  patient  should  be  returned  from  the  Trendelen- 
burg position  to  the  horizontal  slowly.  If  the  horizontal 
is  obtained  too  quickly,  cerebral  angemia  and  circulatory 
shock  may  follow. 

Positions  Favoring  Paralysis  (Figs.  22  and  23). — In 
addition  to  a  pressure  paralysis  of  the  peroneal  nerve, 
which  has  been  taken  up  in  connection  with  the  Trendelen- 
burg position,  we  meet  with  two  other  rather  common  types 
of  paralysis,  secondary  to  an  improper  position  on  the 
table,  namely,  those  of  the  brachial  plexus  and  of  the  mus- 
culospiral  nerve. 

Brachial  Paralysis. — If  the  arms  are  abducted  and 
extended  over  the  head  ( Fig.  22 ) ,  as  sometimes  occurs  in 
the  Trendelenburg  position  where  the  arms  have  been 
fastened  on  the  breast  and  break  loose  from  their  fastening, 
or  in  a  breast  operation,  where  it  is  desirable  to  have  the 
arms  out  of  the  way,  a  brachial  paralysis  is  prone  to  follow. 
This  shows  itself  as  an  Erbs  palsy,  the  deltoid  biceps, 
brachialis  anticus  and  supinator  longus  being  involved. 
In  such  a  palsy  the  arms  hang  down  by  the  sides  and  the 
forearm  cannot  be  flexed. 

This  type  of  paralysis  is  thought  to  occur  from  direct 
overextension  of  the  brachial  plexus ;  in  an  Erbs  paralysis 
the  fifth  and  the  sixth  cervical  nerves  are  chieflv  involved. 


COMPLETE  GENER.\L  ANESTHESIA 


41 


Fig.   20. — Patient  in  Trendelenburg  position — feet  straight. 


I  III.   ^1.  —  The  .-Mijiius  position;  patient  on  left  side,  left  leg  e.\tended,  right  leg  flexed,  left  arm 

behind  and  to  the  side. 


42  ANESTHESIA 

If  the  head  be  turned  to  the  side  during  this  process  of 
overextension,  damage  is  more  pronounced  to  the  plexus 
on  the  opposite  side,  since  it  is  put  on  a  greater  stretch. 

Musculospiral  Paralysis. — If  the  arm  is  permitted  to 
hang  over  the  edge  of  the  table  (Fig.  23),  the  musculo- 
spiral nerve  may  be  compressed  between  the  table  edge  and 
the  bone  and  a  paralysis  results.  This  type  of  paralysis 
is  quite  common,  but  will  never  occur  if  the  arms  are  prop- 
erly cared  for. 

Recovery  from  posture  paralysis  is  usually  complete 
but  protracted.  Symptoms  usually  disappear  first  at  the 
periphery,  and  later  at  the  more  central  portions  involved. 

Position  for  Operation  on  the  Sacrum,  Coccycc  and 
Rectum  (Figs.  25,  26,  27). — When  the  field  of  operation 
is  posterior  to  the  anus,  the  prone  position  (Fig.  25),  or 
its  modification  as  seen  in  Figs.  26  and  27,  is  best  employed. 
The  most  useful  of  these  three  positions  is  the  so-called 
sacral  position  shown  in  Fig.  27 

This  position  may  be  described  as  a  sort  of  a  reversed 
Trendelenburg.  The  control  of  the  respiration  in  this 
position  is  not  nearly  as  troublesome  as  might  appear.  If 
the  head  is  turned  to  one  side  and  the  shoulder  supported 
by  a  small  sandbag,  the  respirations  are  entirely  satisfac- 
tory. A  lighter  degree  of  anaesthesia  may  be  carried  in 
this  position  than  in  almost  any  other. 

This  position  is  the  best  for  coccyxectomy,  resection 
of  the  rectum,  spina  bifida,  etc.  Where  work  is  being  done 
on  the  rectum  a  good  exposure  is  afforded  by  the  falling 
back  of  the  abdominal  viscera.  The  low  position  of  the 
head  is  also  a  protection  against  shock,  and  mucus,  which 
may  collect  in  the  throat,  drains  off  by  gravity. 

Posture  for  Kidney  and  Gall-hladder  Operations  (Figs. 


COMPLETE  GENER^O.  ANAESTHESIA  43 


Fig.  22. — Position  favoring  brachial  paral\  si= 


Fig.  23. — Position  favoring  musculospiral  paralysis. 


44 


ANAESTHESIA 


1  !■     -' t — Position  for  exploration  of  knee-joint. 


Fig.  25. — Prone  position. 


COMPLETE  GENERAL  AX^STHESL\  45 


Fig.  2G. — Prone  position  for  sacral  operation. 


Fig.  27. — Position  for  operation  on  sacrum. 


46  ANESTHESIA 

28,  29,  30,  31,  32,  33) . — While  kidney  operations  are  some- 
times done  with  the  patient  in  the  prone  position,  and  while 
operations  on  the  gall-bladder  are  frequently  accomplished 
with  the  patient  flat  on  the  back,  better  exposure  is  had 
by  employing  the  gall-bladder  kidney  rack  (Fig.  28),  or 
by  breaking  the  table,  as  shown  in  Fig.  31. 

"\^^len  the  i^atient  is  placed  upon  the  table  she  is  made 
to  lie  over  the  rack  or  the  break  in  the  table,  as  the  case 
may  be.  Breaking  the  table  seems  to  be  more  satisfactory 
than  employing  a  rack,  as  the  patient  does  not  so  fre- 
quently complain  of  postoperative  pressure  symptoms. 

If  a  kidney  exposure  is  desired,  the  patient  is  placed  on 
her  side.  The  under  arm  is  carried  behind  her  and  pinned 
to  the  table ;  the  upper  arm  is  flexed  over  the  chest. 

The  position  of  the  legs  is  important.  The  upper  leg 
should  be  extended ;  the  lower  leg  and  thigh  should  be  wxll 
flexed.  This  procedure  will  cause  a  slight  tilting  of  the 
pelvis.  The  crest  of  the  ileum  will  then  be  further  away 
from  the  ribs  on  the  upper  than  on  the  lower  side,  thereby 
increasing  the  field  of  exposure. 

With  the  arms  and  legs  properly  placed,  the  table  is 
then  broken  or  the  rack  is  raised,  as  the  case  may  be  ( Figs. 
29  and  32). 

If  a  gall-bladder  exposure  is  desired,  the  patient  is 
placed  in  the  dorsal  position  over  the  rack  with  the  arms 
to  the  side  or  folded  over  the  chest,  as  in  Figs,  30  and  33. 

Posture  for  Operation  on  the  Neck  ( Figs.  34,  3.5,  36,  37, 
38,  39 ) . — Where  an  operation  is  to  be  performed  upon  the 
thyroid  gland,  the  position  shown  in  Fig.  34  is  that  usually 
employed.  A  small  sandbag  is  placed  under  the  shoulders 
and  another  under  the  nape  of  the  neck.  The  head  is  held 
in  the  middle  line.    If  the  operation  is  to  be  for  glands  of 


COMPLETE  GENERAL  ANiESTHESLV 


47 


Fig.  28. — Table  with  gall-bladder  kidii'v  rnk  in  iiusition. 


Fig.  29. — Patient  in  kidney  position  over  rack. 


48  AN.^STHESIA 

the  neck,  the  same  technic  is  followed  with  the  exception 
that  the  head  is  turned  to  the  side  instead.     (Fig.  3.5.) 

The  Elevated  Neek  Position. — In  the  elevated  neck 
position  the  table  is  arranged  as  for  the  Trendelenburg 
( Fig.  37 ) .  In  this  case  the  head  instead  of  the  knees  ex- 
tends over  the  foot  of  the  table. 

The  patient  is  placed  on  the  horizontal  table  in  such  a 
manner  that  the  head  is  at  the  foot  of  the  table.  The  top 
of  the  shoulders  are  brought  opposite  the  break  in  the  lower 
leaf.  A  stout  linen  bandage  is  then  passed  about  the  feet 
and  tied  to  the  table  suspending  the  patient  in  a  sling  ( see 
Fig.  38)  when  the  table  has  been  elevated. 

The  table  is  then  thrown  up  and  the  head  dropped,  as 
in  Fig.  39.  The  advantages  of  this  position  are  as  follows: 
There  is  less  bleeding  from  the  wound  because  of  the  eleva- 
tion; a  certain  degree  of  cerebral  anemia  obtains  which 
renders  only  a  light  anaesthesia  necessary;  the  field  of 
operation  is  brought  near  to  the  operator,  who  can  thus 
work  with  greater  ease. 

The  Rose  position,  shown  in  Fig.  36,  is  sometimes  em- 
ployed for  operation  upon  the  tonsils  and  adenoids,  the 
object  of  this  position  being  to  keep  the  blood  and  mucus 
out  of  the  respiratory  passages. 

The  Lithotomy  Position  (Figs.  40  and  41). — The 
lithotomy  position  is  that  ordinarily  employed  for  obstetri- 
cal, vaginal,  perineal  and  anal  work. 

Where  this  position  is  emploj^ed  for  anal  operations  on 
strong,  muscular  patients  or  where  only  a  light  anaesthesia 
is  to  be  administered,  it  is  well  to  put  the  shoulder  braces 
in  place.  This  will  prevent  the  patient  from  pushing  her- 
self away  from  edge  of  table,  should  she  become  rigid. 

The  buttocks  should  be  extended  well  over  the  edsre  of 


COMPLETE  GENERAL  ANJ^:STHESL\  49 


Fig.   30. — Patient  in  gall-bladder  position  over  raok. 


Fir,.   31. — Table  broken  instead  of  raising  rack. 


50 


ANESTHESIA 


Fig.  32. — Kidney  position  on  broken  table. 


Fig.  33. — Gall-bladder  position  on  broken  table. 


COIVIPLETE  GENERAL  ANAESTHESIA  51 


Fig.   34. — Ordinary  neck  position  for  goitre  opcratioa. 


Fig.  35. — Ordinary  neck  position  for  glands  of  neck. 


52 


ANESTHESIA 


Fra.  36. — The  Rose  position. 


Fig.  37. — The  elevated  neck  puaitiuu. 


COMPLETE  GENERAL  AN^ESTHESLA.  53 


Fig.  38. — The  table  set  for  elevated  neck  ijusiii.m. 


Fig.  39. — Patient  in  clevuiud  iiurk  ij'>.-itiL 


54  ANESTHESIA 

the  table  so  that  the  weighted,  vaginal  speculum  ordinarily 
used  may  hang  free. 

Anaesthesia  may  be  induced  with  advantage  in  the 
lithotomy  position  where  the  oj^eration  is  to  be  a  curettage 
or  some  slight  anal  operation.  By  this  method  one  need 
not  wait  for  relaxation  of  the  large  thigh  and  calf  muscles 
liefore  prej^arations  are  begun. 

Posture  for  the  Closure  of  U pper  Abdominal  Wounds 
(Figs.  42  and  43). — Complete  relaxation  for  the  closure 
of  upper  abdominal  wounds  is  often  difficult  to  obtain.  If 
the  head  and  the  foot  of  the  table  are  raised,  as  is  shown 
in  Figs.  42  and  43,  relaxation  will  be  materially  assisted. 

Tlie  Watcher  Position. — The  Walcher  or  Hanging 
Position  is  purely  for  obstetrical  purposes.  The  object  of 
this  position  is  to  increase  the  diameter  of  the  pelvic  inlet 
by  tilting  the  symphysis  pubis,  as  shown  in  Fig.  44.  This 
tilting  increases  the  conjugata  vera  about  one  centimetre 
(Fig.  45).  The  position  is  obtained  by  allowing  the 
patient  to  rest  on  the  edge  of  the  table  on  the  buttocks 
with  her  legs  hanging  free.     (  Fig.  44.) 

7.  Rigidity  in  upper  abdominal  operations  is  particu- 
larly embarrassing  when  the  wound  is  closed.  At  this 
time  great  relief  is  afforded  the  surgeon  by  lifting  the 
head  of  the  table,  thereby  relieving  the  tension  on  the  recti 

(refer  to  Figs.  42  and  43). 

8.  Rigidity  caused  by  intra-abdominal  distention,  which 
has  not  been  relieved  by  the  operation,  is  best  dealt  with 
by  using  an  open  mask,  at  least  during  the  stage  of  main- 
tenance. In  this  way  the  maximum  oxygenation  is 
obtained  and  there  is  practically  no  residual  COo  to  cause 
deep  and  embarrassing  respirations.  These  cases  are  usu- 
ally quite  sick  and  succumb  easily  to  the  anjesthetic. 


COMPLETE  GENERAL  AN^STHESLV 


55 


Fig.  40. — Table  set  for  lithotomy. 


Fig.  41. — Patient  in  lithotomy. 


56 


ANESTHESIA 


Fig.   42. — Table  set  for  closure  of  upper  abdominal  wounds. 


Fig.   43. — Patient  in  position  for  tlcsure  cf  upper  abdominal  wounds. 


COMPLETE  GENERAL  AN^STHESL\  57 

9.  Rigidity  is  caused  by  the  anaesthetic  per  se:  Where 
all  rigidity  must  be  abolished,  mtrous  occide  and  (hvygen 
alone  will  not  give  a  uniform  and  satisfactory  result  in 
abdominal  operations.  Preliminary  medication  and  nerve 
blocking  or  ether  must  be  used. 


Fig.  44. — The  Walcher  position. 

The  Third  Period  of  Induction:    Relaxation 
Relaxation  is  more  than  mere  absence  of  rigidity.  In  the 
normal  muscle,  which  is  not  rigid,  there  is  a  definite  tone 
which  differentiates  it  from  the  muscle  which  is  completely 
cut  off  from  the  control  of  the  central  nervous  system. 

A.  The  Evidences  of  Relaxation. — At  the  begin- 
ning of  the  stage  of  induction  before  excitement  ha.s  become 
apparent,  one  frequently  finds  a  condition  of  pseudo-re- 
laxation. The  arms  and  legs  can  be  fiexed  and  extended, 
remaining  quietly  in  place.    L^pon  a  casual  observation  it  is 


58  .-VNiESTHESIA 

almost  impossible  to  differentiate  this  condition  from  that 
of  true  relaxation.  In  the  case  of  children,  where  it  is  quite 
commonly  found,  it  may  sometimes  be  detected  by  sharply 
tapping  the  platysma  myoides  of  the  extended  side ;  if  the 
patient  is  simply  sleeping  there  will  be  a  sympathetic  dila- 
tion of  the  pupil  of  the  same  side.  This  condition  of 
pseudo-relaxation  may  be  accounted  for  in  the  following 
manner:  During  the  period  in  question,  the  anaesthetic  is 
producing  chiefly  cerebral  effects  or  no  effect  at  all.     The 

10.9 u-rr^       motor  nerves  have  lost  none 

of  their  irritability.  They 
are  simply  receiving  no 
stimuli.  The  condition  is 
much  like  that  of  natural 
sleep.  Later  the  physio- 
logical effects  of  the  ether 
become  evident  in  a  dis- 
charge of  energy,  which  ex- 

Fro.  45.— Diagram  to  explain  Walcher  position,      ViiViifc     i  +  cf^lf     in     rTP>r»fiTnl     nr 
seep.  57.     (After  Williams' Obstetrics.)  niOlLS    llSCll     111    geiieitll     OI 

local  rigidity.  Relaxation  appearing  shortly  after  the 
anesthetic  has  commenced  and  which  has  not  been  preceded 
by  a  definite,  however  brief,  stage  of  excitement  should  be 
regarded  with  suspicion. 

OccasionrJly  true  relaxation  does  come  on  in  this  man- 
ner, but  this  is  unusual. 

The  preliminary  use  of  morphine  may  so  far  do  away 
with  the  period  of  excitement  that  its  presence  is  not  noted. 
In  such  cases,  true  relaxation  will  come  on  with  a  quietness 
and  rapidity  which  will  strongly  suggest  the  pseudo-state. 
One  must  not  depend  solely  upon  the  evidences  of  relaxa- 
tion. These  must  be  corroborated  by  the  condition  of  the 
lid  and  eve  reflexes. 


COMPLETE  GENERAL  AN.ESTHESL\  59 

True  relaxation  may  often  be  distinguished  from  the 
spurious  by  examining-  the  condition  of  the  masseters.  It 
will  usually  be  found  that  in  true  relaxation  the  lower  jaw 
can  be  made  to  move  freely  up  and  down,  while  with 
pseudo-relaxation,  the  teeth  are  tightly  clenched. 

B.  The  Causes  of  True  Relaxation. — Relaxation 
may  be  said  to  occur  when  the  deep  muscle  stimuli,  which 
are  constantly  flowing  to  the  normal  muscle,  have  been 
inhibited  by  the  action  of  the  anaesthetic. 

This  action,  while  affecting  chiefly  the  nervous  mechan- 
ism, may  also  be  due  to  the  direct  effect  of  anaesthetic  upon 
the  muscle  tissue,  rendering  it  less  responsive  to  stimuli. 

Whether  or  not  the  efferent  motor  mechanism  is  para- 
lyzed to  the  exclusion  of  the  afferent  sensorv,  as  suo:o:ested 
by  Crile,  is  still  open  for  discussion.  However  this  may  be, 
we  may  account  for  muscular  relaxation  by  supposing  an 
anaesthetic  "  block  "  acting  on  the  motor  nerves. 

Loss  of  rigidity  does  not  imply  complete  relaxation. 
We  must,  as  already  remarked,  dispose  of  the  normal  tone 
of  the  muscle  before  the  desired  end  can  be  obtained. 

C.  The  Control  of  the  Relaxation. — If  the  pain 
stimuli  are  absent  or  diminished,  the  rigidity,  which  occurs 
as  a  reflex  effect  of  this  irritation  will  also  be  controlled. 
Local  antesthesia  applied  to  the  sensory  nerve  endings,  as, 
for  example,  the  injection  of  novocaine  into  the  sensitive 
operative  field,  before  incising,  will  result  in  an  absence  of 
rigidity  on  the  part  of  those  muscles,  which  would  nor- 
mally be  involved  in  this  reflex.  Under  a  light  anaesthesia, 
such  as  that  secured  by  nitrous  oxide  and  oxygen  there  is 
no  doubt  as  to  this  action. 

The  control  of  the  relaxation  then  is  largely  the  duty  of 
the  antEsthetist,  who  will  bring  about  the  best  results  by 


60  ANESTHESIA 

removing  and  controlling  as  far  as  possible  the  causes  of 
rigidity,  i.e.,  excitement,  obstruction  to  the  respiration,  too 
early  incisions,  position  of  patient,  operations  on  upper 
abdomen,  gall-bladder  and  pelvic  stimuli,  dilatation  of 
sphincter,  anesthetic  per  se  and  intra-abdominal  distention. 

II.  MAINTENANCE 

Having  treated  the  first  stage  of  a  complete  general 
anaesthesia,  induction,  we  now  proceed  to  the  second  stage, 
maintenance. 

The  stage  of  maintenance  begins  when  general  relaxa- 
tion obtains,  and  when  a  constant  depth  of  anaesthesia  has 
been  reached.  It  ends  when  the  level,  which  has  been  held, 
is  permanently  permitted  to  drop. 

Two  varieties  of  maintenance  may  be  noted:  the  con- 
stant maintenance  and  the  variable  maintenance. 

Constant  maintenance  (Fig.  46)  can  only  be  obtained 
by  means  of  a  special  mechanical  device  made  for  the  pur- 
pose of  delivering  vapor  in  known  percentages. 

Variable  maintenance  is  the  tyj^e  which  occurs  when 
anaesthesia  is  otherwise  carried  on. 

Constant  maintenance  keeps  the  patient  so  completely 
anesthetized  throughout  the  operation  that  he  will  not 
inconveniently  react  to  deeper  stimuli.  This  type  of  antes- 
sia  protects  the  patient  from  afferent  pain  stimuli,  and 
considers  the  amount  of  ether  used  as  of  little  consequence. 

The  varying  type,  which  obtains  when  the  open,  semi- 
open  or  closed  drop  method  is  used,  aims  to  anticipate  and 
hold  in  abeyance  the  reflex  effects  of  trauma  to  the  deeper 
structures,  by  increasing  the  anesthesia  according  to  indi- 
cations. It  aims  to  lessen  the  amount  of  ether  used  by 
allowing  a  lighter  level  as  often  as  possible. 

By  a  varying  maintenance  is  meant  one  which  varies 


COMPLETE  GENERAL  AN.i^STHESL\ 


61 


only  under  the  immediate  direction  and  control  of  the 
antusthetist.  The  anaesthetist  must  always  be  in  tlie  "  lead," 
so  to  speak.  He  must  always  know  just  where  the  patient 
is  and  anticipate  the  call  for  a  lighter  or  deeper  anesthesia. 
For  this  reason  he  should  be  familiar  with  the  operative 
procedure.  He  should  know  the  technic  and  the  demands 
of  the  surgeon  with  whom  lie  works.  Some  surgeons  ap- 
preciate a  light  anaesthesia,  while  others  will  not  tolerate  it. 


lao 


MIN 


Fig.  46. — Curve  showing  variable  and  constant  maintenance;  constant  maintenance  shown 
by  dotted  line,  variable  by  solid. 

The  anaesthetist  should  know  something  of  the  relative  sen- 
sitiveness of  the  various  tissues.  He  should  know  that  the 
skin  and  the  peritoneum  react  much  more  energetically 
than  the  muscle  and  bone  tissues.  With  this  knowledge,  he 
will  not  be  surprised  in  an  operation  for  inguinal  hernia, 
for  example,  to  find  the  patient,  who  is  going  along  peace- 
fullv  enough  throug'h  the  dissection  of  the  involved  mus- 
cles,  suddenly  come  out  of  the  anaesthesia  when  traction  is 


62  ANAESTHESIA 

made  upon  the  hernial  sac,  whose  formation,  it  will  he  re- 
membered, is  peritoneal. 

If  we  were  positive  that  the  amount  of  ether  made  no 
difference,  from  a  ^pathological  point  of  view,  and  if  we  were 
sure  that  a  deep  ansesthesia  afforded  an  absolute  nerve 
block,  it  would  be  very  poor  technic  to  use  any  method  but 
that  which  will  give  a  constant  level.  In  view  of  the  present 
theories  touching  upon  nerve  block  and  shock,  however,  and 
our  incomplete  information  regarding  the  massive  effects 
of  ether  on  the  blood  and  tissues,  we  are  justified  in  feeling 
that  this  varying,  or  as  is  sometimes  called,  empirical 
method,  is  really  not  so  unreasonable  after  all. 

The  control  of  the  stage  of  maintenance,  as  has  already 
been  stated,  depends  very  largely  upon  the  character  of 
the  induction.  A  stormy  and  delayed  induction  will  very 
likely  give  rise  to  a  stage  of  maintencnce  which  is  uneven 
and  difficult  to  control. 

The  obstruction  of  the  respiration  is  one  of  the  most 
important  elements  in  the  control  of  the  stage  of  main- 
tenance. Persistent  obstruction,  during  this  stage,  usually 
results  in  undesirable  lightness  with  consequent  rigidity, 
increased  bleeding,  and  cyanosis.  The  paralysis  of  the 
tongue,  which  frequently  causes  this  obstruction,  can 
readily  be  relieved  by  the  use  of  the  throat  tube  (Fig.  14) , 
whose  great  value  we  once  more  emphasize.  Other  types 
of  obstruction,  such  as  laryngeal,  pulmonary,  intra-  and 
extra-abdominal  pressure,  must  be  separately  and  success- 
fully dealt  with,  if  one  washes  a  smooth  maintenance. 

If  the  respiration  is  deep  and  free,  the  patient  must  be 
carefully  watched  for  signs  of  recovery;  for  it  will  be 
readily  appreciated  that  such  a  respiration  will  soon  dis- 
pose of  the  ether  which  may  be  in  the  patient's  circulation. 


COMPLETE  GENERAL  ANiESTHESLV  63 

Such  patients  call  for  an  increased  amount  of  ether  on  the 
open  mask  or  the  continuous  use  of  the  closed  method. 

On  the  other  hand,  tlie  patient  whose  respirations  are 
shallow  is  conserving  most  of  the  ether  in  his  system  and 
requires  but  a  small  amount  to  maintain  the  level  in  which 
we  find  him.  This  is  quite  typical  of  the  patient  who  has 
received  preliminary  morphine  medication. 

Occasionally  one  sees  a  patient  in  the  stage  of  main- 
tenance forgotten  for  the  time  being  by  the  auiesthetist, 
because  of  his  lack  of  knowledge  of  the  signs  playing 
before  his  eyes,  and  because  custom  has,  so  to  say.  decreed 
that  his  work  of  "  carrying  the  patient  to  the  brink  of  the 
grave  and  leading  him  safely  back  again  "  is  not  quite:  so 
important  as  holding  the  retractors  and  looking  into  the 
patient's  belly.  Such  a  neglected  patient  may  do  one  of 
two  things:  If  the  antcsthetist  wishes  to  make  sure  of  not 
being  disturbed  during  his  observations,  and  as  a  safeguard 
against  this  annoyance,  pours  on  ether  without  watching 
the  patient,  the  latter  may  die,  as  has  occurred  not  infre- 
quently under  precisely  such  conditions.  In  this  case  the 
anaesthetist  is  not  discharged  from  the  hospital  for  criminal 
negligence,  but  the  cause  of  death  is  registered  as  cardiac 
failure  or  status  lymphaticus,  which,  however,  does  not 
clear  the  anaesthetist  of  serious  guilt,  due  to  his  negligence. 
Or  should  the  ansesthetist,  bearing  in  mind  these  fatalities, 
in  the  course  of  his  bird's-eye  view  of  the  field  of  opera- 
tions, stop  giving  ether  for  safety's  sake,  then  the  patient 
does  the  other  of  the  two  things — he  vomits.  This  invaria- 
bly directs  the  condemning  glances  of  the  staff  directly  to 
the  antEsthetist.  As  a  result,  anxious  to  cover  up  matters 
as  quickly  as  possible,  he  does  just  the  wrong  thing.  He 
immediately  pushes  the  ether  to  the  utmost. 


64  ANESTHESIA 

The  onset  of  vomiting  implies  the  return  of  the  pharyn- 
geal reflexes.  The  reaction  to  ether  is  now  much  as  it  was 
in  the  early  periods  of  induction;  concentrated  ether  gives 
rise  to  spasm,  rigidity,  and  delayed  induction.  The  anaes- 
thetist, in  his  anxiety  to  bring  the  patient  back  to  the  stage 
of  maintenance,  defeats  his  own  ends.  The  aucTsthetic 
should  be  given  slowly  until  a  tolerance  is  established.  It 
may  then  be  pushed  to  the  desired  level  without  ill  effects. 

^^^lile  the  stage  of  maintenance,  therefore,  may  on  the 
surface  appear  quite  simple,  it  is  fraught  with  danger  to 
the  patient  and  inconvenience  to  the  surgeon,  unless  in- 
telligently carried  out. 

From  the  surgeon's  point  of  view  the  stage  of  main- 
tenance should  have  no  varying  levels.  It  should  be 
absolutely  smooth.  When  indicated,  relaxation  should  be 
complete  and  respiration  of  such  depth  that  it  will  not  in- 
terfere with  intra-abdominal  manipulations.  With  Ihe 
variable  type  of  maintenance  this  ideal  is  approached  and 
will  become  j^erf  ect  according  to  the  skill  of  the  anaesthetist. 

With  constant  or  unvarying  maintenance,  devised  by 
Dr.  Connell,  it  is  the  exception  to  fall  short  of  this  ideal. 

Constant  maintenance  implies  the  use  of  definite  per- 
centages of  ether.  Technically  such  a  percentage  is  sj^oken 
of  as  vapor  tension. 

The  Percextage  or  Vapor  Tension  of  Ether. — A 
short  explanation  must  be  given  of  the  physical  laws  which 
govern  the  transfer  of  ether  from  the  liquid  state  in  the 
ether  can  to  the  state  of  solution  in  the  blood  and  nervous 
system  of  the  patient. 

"  The  air  around  us  exists  under  a  pressure  of  one 
atmosphere  and  this  pressure  is  expressed  usually  in  terms 
of  the  height  of  a  column  of  mercury  that  it  will  support — 


COMPLETE  GENERAL  ANAESTHESIA 


65 


namely  a  column  of  760  mm.  Hg  which  is  known  as  the 
normal  barometric  pressure  at  sea  level.  Air  is  a  mixture 
of  gases  and  according  to  the  mechanical  theory  of  gas 
pressure  each  constituent  exerts  a  pressure  corresponding 
to  the  proportion  of  that  gas  present.  In  atmospheric  air, 
therefore,  the  oxygen  being  present  to  the  extent  of  20 
per  cent,  exerts  a  pressure  of  1/.5  of  an  atmosphere  or  1  .> 
of  760 — 162  mm.  of  Hg.  (A  saturated  atmosphere  of  ether 
vapor  under  like  conditions  exerts  a  vapor  pressure  of 
68  mm.  Hg  at  -  20°  C,  182  mm.  Hg  at  0°  C,  and  about 
460  mm.  at  ordinary  room  temperature. ) 


Induction.  Maintenance.  Recovery. 

Fig.   47. — Diagram  showing  vapor  tension  of  ethier  in  alveolar  air  during  the 

three  stages  of  a  complete  anaesthesia. 

"  When  a  gas  is  brought  into  contact  with  a  liquid  with 
which  it  does  not  react  chemically,  a  certain  number  of  the 
moving  gaseoaas  molecules  penetrate  the  liquid  and  become 
dissolved.  As  many  molecules  will  penetrate  the  liquid  in 
a  given  time  as  escape  from  it,  and  the  liquid  will  hold  a 
definite  number  of  the  gas  molecules  in  solution,  it  will  be 
saturated  for  that  pressure  of  the  gas.  If  the  pressure  of 
the  gas  is  increased,  however,  an  equilibrium  will  be  estab- 
lished at  a  higher  level  and  more  molecules  of  the  gas  will 
be  dissolved  in  the  liquid.  Experiments  have  shown,  in 
accordance  with  this  mechanical  conception,  that  the 
amount  of  a  given  gas  dissolved  by  a  given  liquid  varies, 
the  temperature  remaining  the  same,  directly  with  the  pres- 
sure, that  is,  it  increases  and  decreases  proportionally  with 

5 


66  ANAESTHESIA 

the  rise  and  fall  of  the  gas  pressure.  This  is  the  law  of 
Henry.  On  the  other  hand  the  amount  of  gas  dissolved 
by  a  liquid  varies  inversely  with  the  temperature.  It  fol- 
lows also  from  the  same  mechanical  views  that  in  a  mixture 
of  gases  each  gas  is  dissolved  in  proportion  to  the  pressure 
which  it  exerts,  and  not  in  proportion  to  the  pressure  of 
the  mixture. 

"  Air  consists  in  round  numbers  of  four  parts  of  nitro- 
gen and  one  part  of  oxygen.  Consequently  when  a  vol- 
ume of  water  is  exposed  to  the  air,  the  oxygen  is  dissolved 
according  to  its  '  partial  pressure,'  that  is,  under  a  pressure 
of  15  of  an  atmosphere  ( 1,52  mm.  of  Hg) .  The  water  will 
contain  only  1/5  as  much  oxygen  as  it  would  if  exposed  to  a 
full  atmosphere  of  oxygen,  that  is,  pure  oxygen.  And  on 
the  other  hand  if  water  has  been  saturated  with  oxygen 
at  one  atmosphere  760  mm.  of  pressure  and  is  then  exposed 
to  the  air,  4/5  of  the  dissolved  oxygen  will  be  given  off, 
since  the  pressure  of  the  surrounding  oxygen  has  been 
diminished  this  much. 

"  When  a  gas  is  held  in  solution  the  equilibrium  is 
destroyed  if  the  pressure  of  this  gas  in  the  surrounding 
medium  or  atmosphere  is  changed.  If  this  pressure  is  in- 
creased the  liquid  takes  up  more  of  the  gas,  as  an  equi- 
librium is  established  at  a  higher  level.  If  the  pressure  is 
decreased  the  liquid  gives  off  some  of  the  gas.  That  pres- 
sure of  the  gas  in  the  surrounding  atmosphere  at  which 
equilibrium  is  established  measures  the  tension  of  the  gas 
in  the  liquid  at  the  time.  Thus  when  a  bowl  of  water  is 
exposed  to  the  air  the  tension  of  the  oxygen  in  the  solution 
is  152  mm.  Hg;  that  of  the  nitrogen  608  mm.  Hg.  If  the 
same  water  is  exposed  to  pure  oxygen  the  tension  of  the 
oxygen  in  solution  is  equal  to  760  mm.  Hg,  while  that  of 


COMPLETE  GENERAL  AN.ESTHESL\  67 

the  nitrogen  sinks  to  zero  if  the  gas  that  is  given  off  from 
the  water  is  removed.  With  compounds  such  as  oxyhfemo- 
glohin  the  tension  under  wliich  the  oxygen  is  held  is  meas- 
ured by  the  pressure  of  the  gas  in  the  surrounding  atmos- 
phere at  which  the  compound  neither  takes  up  nor  gives  off 
oxygen.  If,  therefore,  it  is  necessary  to  determine  the 
tension  of  any  gas  held  in  solution  or  in  dissociable  com- 
bination it  is  sufficient  to  determine  the  percentage  of  that 
gas  in  the  surrounding  atmosphere  and  thus  ascertain  the 
partial  pressure  which  it  exerts.  If  the  atmosphere  con- 
tains 5  per  cent,  of  a  given  gas  the  partial  pressure  exerted 
by  it  is  equal  to  38  mm.  Hg  ( 760  times  .0.5 )  and  this  figure 
expresses  the  tension  under  which  the  gas  is  held  in  solution 
or  combination  in  a  liquid  exposed  to  such  an  atmosphere. 
(If  the  atmosphere  contains  6..58  per  cent,  of  ether  vapor 
the  partial  pressure  exerted  by  it  is  50  mm.  Hg.) 

"  It  is  important  not  to  confuse  the  tension  at  which  a 
gas  is  held  in  a  liquid  with  the  volume  of  the  gas.  Thus 
blood  exposed  to  the  air  contains  its  oxygen  under  a  ten- 
sion of  152  mm.  Hg  but  the  amount  of  oxygen  is  equal  to 
twenty  volumes  per  cent.  Water  exposed  to  the  air  con- 
tains its  oxygen  under  the  same  tension  but  the  amount  of 
gas  in  solution  is  less  than  one  volume  per  cent.  Ten- 
sions of  gases  in  liquids  are  expressed  either  in  percentages 
of  an  atmosphere  or  in  millimetres  of  mercury.  Thus  the 
tension  of  oxygen  in  arterial  blood  is  found  to  be  equal  to 
about  10  per  cent,  of  an  atmosphere  of  76  mm.  Hg.  "  (  The 
tension  of  ether  vapor  necessary  to  maintain  amesthesia  is 
about  50  mm.  Hg. ) " — Howell ;  matter  in  parentheses  ours. 

Were  it  of  advantage  that  a  saturated  atmosphere  of 
ether  at  room  temperature  be  breathed  by  a  patient,  so 
much  ether  could  be  dissolved  in  the  blood  that  the  vapor 


68 


ANESTHESIA 


tension  of  the  ether  dissolved  would  finally  equal  that  of 
the  vapor  in  the  lung,  or  460  millimetres.  Yet  it  is  found 
clinically  that  a  sufficient  depth  of  antesthesia  has  heen 
achieved  when  the  amount  dissolved  in  the  blood  has  a 
vapor  tension  of  50  millimetres.  To  insure  this  amount  be- 
ing dissolved  into  the  blood  within  a  reasonable  time, — six 
to  eight  minutes  being  usually  employed  in  induction — it 


laOmm 

150""" 

120  mm 

90""" 
75  mm. 

50mm 

30""" 


TIME        *^ 
STAGE 


460"""- 

SATURATION  ®22«C 

ASPHYXIAL    INDUCTION    ZONE 

RAPID     AND      DANCCROUS 

ZONE  FOR  RESISTANT     SUBJECTS 

/rapid  induction\ 

/        RtLAXATION           \ 
/           IN    r-IO   MIN              \ 

/  y^      SLOW    IMDUCnON       V     \ 
//                  RELAXATION                  X\ 
//                     IN  12-15    MIN.                         -X 

/ 
/ 

IRRITATION,  MUCOUS                                  \ 
SUBCONSCIOUS  EXCITEMENT 

\ 

/fsLIGHT   IRRITATION                                                   [^v 
/(CONSCIOUS   EXCITEMENT                                        1        \^ 

/ 

PUNGENT  ODOR 

CONFUSION  AND  SOMNOLENCE 

ANAESTHETIC 

Aether    odor 
/[sugmt  confusion 

1 

1 

!    EQUILIBRIUM 

»  — 

^3 

-5MIN.                J^              5-7  MIN. 

"induction 

20-40MIN. 

'  FUUL  surgical' 

■  J^  MANY   HOURS  ^ 

ANAESTHESIA  "  ^ 

Fig.  48. — Vapor  pressure  of  ether  in  tidal  air  for  induction  and  maintenance  of  full  ansesthesia.   Partial  press- 
ure of  vapor  in  millimetres  of  mercury     (Courtesy  of  Dr.  K.  Connell,  Johnson's  Surgery,  Appleton.) 

is  required  that  a  much  stronger  ether  vapor  be  breathed 
during  induction  than  is  needed  merely  to  maintain  anses- 
thesia.   ( Figs.  48  and  49) . 

To  induce  anassthesia  rapidly,  the  vapor  must  be  so 
abundant  as  to  exert  a  vapor  tension  of  at  least  180 
millimetres  (Figs.  48  and  49).  This  gradually  crowds 
the  required  amount  of  ether  into  the  blood  and  nervous 
system.  When  the  blood  approaches  the  proper  satura- 
tion, as  indicated  by  the  signs  of  anaesthesia,  the  amount 


COMPLETE  GENERAL  ANAESTHESIA 


69 


of  ether  present  in  the  air  breathed  is  gradually  lowered 
until  finally,  in  ideal  anesthesia,  the  pressure  of  ether  vapor 
in  the  lung  balances  the  tension  of  ether  dissolved  in  the 
blood  and  the  patient  sleeps  in  quiet,  uniform  anaesthesia  of 
the  desired  depth.  This  is  finally  achieved  at  a  level  of  .50 
millimetres  of  ether  tension;  or  by  volumetric  percentage 

120-  ISC'"' 


50^ 


ANAESTHETIC  EQUILIBRIUM 
ESTABLISHED  AT  50'"'" 


r\mm 
TtME                 8-12    MIN. 
AVERAGE  ADULT     < 


20-  4-0      MIN. 


>!<- 


PERIOD     <      INDUCTION       X     ESTABLISHMENT     )^       CONTINUANCE 

Fia.  49. — Plot  of  ether  vapor  pressure  in  pulmonary  tidal  air  and  ether  tension  in  body  in  6rst 
hour  of  ideal  anaesthesia.     (Courtesy  of  Dr.  K.  Connell,  Johnson's  Surgery,  Appleton.) 

6.o8  per  cent,  of  the  air  breathed  should  be  ether  vapor 
(Figs.  48,  49  and  50).     At  this  level,  both  the  small  child 
and  robust  alcoholic  sleep  in  anaesthesia  of  proper  dej)th. 
The  foregoing  facts  throw  light  on  the  following : 
The  value  of  warming  liquid  ether  to  promote  evapora- 
tion (not  the  value  of  warming  ether  vapor,  which  is  nil). 
Safety  of  the  open  drop  mask  with  its  hoar  frost  evapo- 
rating surface  (much  reduced  evaporating  temperatm-e). 


70 


ANAESTHESIA 


The  efficiency  of  the  closed  system  of  aricEsthetization 
(because  of  the  heat  from  rebreathing) . 

The  greater  efficiency  of  using  a  warmed  apparatus 
(warm  metal)  for  induction. 

If  one  sets  an  ether  vapor  bottle  in  water  100°  F.,  the 
ether  vapor  which  issues  approaches  100  per  cent,  instead  of 
being  60  per  cent.  (460mm.  of  760mm.)  or  less  (see  p.  148). 

If  with  the  semi-open  method  the  patient  rebreathes  a 
little,  this  increased  heat  serves  to  give  us  better  control 
of  the  patient. 


>^^^ 


TIME 

Fig.   50. — Plot  of  ether  tension  in  body.     Recovery  stage  after  full  ether  anaesthesia. 
(Courtesy  of  Dr.  K.  Connell,  Johnson's  Surgery.) 

The  Volume  Employed. — Following  the  question  of 
vapor  tension  or  the  strength  of  the  ether  vapor,  the  bulk  of 
the  vapor  administered  is  our  next  consideration.  In  order 
that  the  respiration  may  be  tranquil,  a  sufficient  volume 
must  be  administered.  The  amount  necessary  varies  ac- 
cording to  the  individual  from  10  to  18  litres  a  minute. 

The  indicator  on  the  ana^sthetometer  shows  the  volume 
which  is  being  delivered,  and  we  are  provided  with  the 
means  to  regulate  automatically  the  amount  of  ether  added 
to  each  litre  and  the  consequent  percentage  of  ether  vapor. 


COMPLEIE  GENERAL  ANAESTHESIA  71 

The  Pressure  at  which  the  Vapor  is  Deli^t:red. — 
This  vapor,  wliicli  is  now  being  delivered  in  sufficient  vol- 
ume to  fill  all  the  requirements  for  tidal  volume  and  at  a 
percentage  which  is  constantly  under  our  control,  must  be 
administered  to  the  patient  at  a  pressure  sufficient  to  carry 
it  deej)  into  the  pharynx  and  to  exclude  atmospheric  air. 

The  necessary  volume  of  10  to  18  litres  a  minute 
should  be  delivered  at  a  pressure  of  from  15  to  30  mm., 
according  to  the  individual  in  question.  The  volume  is  in- 
tended to  be  in  excess  to  the  respiratory  needs  and  this 
delivery,  under  the  pressure  mentioned  above,  practically 
provides  the  patient  with  an  atmosphere  of  a  known  and 
constant  percentage. 

We  have  now  considered  and  explained  vapor  pressure 
or  tension;  seen  the  need  of  a  vapor  pressure  of  180  mm.  or 
more  for  the  stage  of  induction,  and  have  established  a 
vaj3or  pressure  of  50  mm.  as  a  safe  and  satisfactory  press- 
ure for  maintenance.    For  apparatus  see  Fig.  78. 

Control  of  Maintenance. — The  control  of  main- 
tenance resolves  itself  into:  First,  the  undivided  and  in- 
terested attention  of  the  anaesthetist.  Anything  which  has 
a  tendency  to  interfere  with  this  should  be  eliminated,  as 
trouble  is  certain  to  follow  sooner  or  later.  Second,  the 
patient  must  be  the  final  index  governing  the  quality  and 
the  amount  of  the  anaesthetic.  The  patient  must  never  be 
forced  against  all  his  protesting  signs  to  accept  what 
is  theoretically  correct.  The  art  of  ana?sthesia  does  not 
permit  us  to  court  the  patient's  death  in  this  fashion.  If, 
for  example,  the  surgeon  complains  of  rigidity  during  the 
course  of  maintenance,  remarking,  "  Won't  you  please  get 
him  under,"  or  "  he  is  like  a  board,"  or  simply  stops  his 
procedure  and  looks  at  you  in  unutterable  disgust,  do  not 


72  ANAESTHESIA 

soak  the  patient  with  ether  in  the  presence  of  a  dilated 
pupil,  absent  corneal  reflex,  and  cyanosis.  Be  absolutely 
certain  that  you  know  the  cause  of  the  rigidity.  Be  sure 
that  the  respirations  are  free  and  that  the  position  on  the 
table  is  good ;  that  the  patient  is  really  light  before  you  go 
ahead,  and  to  protect  yourself  from  abuse,  give  him  the  last 
push  which  sends  him  "  over  the  brink."  You  are  the  pilot 
on  the  ship  Patient.  It  is  your  duty  to  look  out  for  the 
shoals  and  the  breakers  which  threaten  her  course.  Who 
ever  heard  of  a  trustworthy  pilot  leaving  the  wheel  to  lose 
himself  in  some  diversion  going  on  aboard?  Do  not  let 
your  first  warning  be  a  scraping  of  the  keel  as  she  rides  over 
shallows,  that  is  to  say,  when  the  patient  begins  to  retch ;  or 
the  sudden  startling  sound  of  breakers,  as  the  respirations 
become  sighing  and  cease,  and  cyanosis  becomes  deeper  and 
deeper,  the  eyelids  widely  separated  and  the  pupils,  with 
the  iris  almost  gone,  staring  through  a  lustreless  cornea. 
Unless  one  is  a  careful  and  observant  pilot  all  the  time,  he 
will  find  himself  drifting  from  the  course  and  endangering 
the  life  of  this  human  being  so  wholly  under  his  control. 

We  must  realize  that  this  business  is  a  most  serious  one ; 
that  its  frequent  execution  by  the  youngest  and  most  inex- 
perienced interne  is  a  most  unjust  thing.  That  in  this  mat- 
ter the  house  officers,  who  incidentally  rank  above  you  and 
who  have  given  a  few  hundred  anaesthetics  are  not  so  expert 
that  from  their  position  at  the  retractors  they  can  give  you 
precise  long-distance  information  as  to  the  immediate  needs 
of  the  patient.  The  color,  the  respirations,  the  pulse  and 
the  eye  signs  are  our  masters.  Learn  well  how  to  obey 
these  and  all  will  go  smoothl3\  If  the  surgeon  and  the 
senior  house  officers  would  force  the  anesthetist  to  study  the 
symptoms  carefully  and  to  be  personally  responsible  for 


COMPLETE  GENERAL  ANAESTHESIA 


73 


74  AN.^.STHESIA 

everything  incidental  to  the  anaesthetic,  accepting  freely, 
in  case  of  doubt,  the  opinion  of  their  pilot,  a  smoother  and 
a  safer  anaesthesia  would  result. 

We  have  considered  the  onset  of  the  stage  of  mainte- 
nance, the  constant  and  variable  types  available  for  our 
use  and  the  responsibility  of  the  anaesthetist  towards  the 
patient.  Let  us  now  take  up  the  question:  When  does 
the  stage  of  maintenance  properly  cease  and  the  stage  of 
recovery  begin? 

Maintenance  ceases  when  we  leave  the  constant  or  vari- 
able level,  which  we  have  held  and  reduce  or  stop  the  anaes- 
thetic XLith  a  view  of  bringing  the  patient  back  to  con- 
sciousness. While  carrying  on  a  variable  maintenance,  we 
may  reduce  and  even  stop  the  anaesthetic ;  but  we  do  not  do 
this  with  a  view  of  bringing  about  the  complete  recovery 
of  the  patient.  The  motive  which  leads  us  to  finally  stop 
the  anaesthetic  is  that  which  really  constitutes  the  dividing 
line  between  the  stages  of  maintenance  and  recovery. 

III.  THE  STAGE  OF  RECOVERY 

This  stage  begins  with  the  permanent  reduction  of  the 
anaesthetic  and  ends  with  the  return  of  consciousness. 

Because  the  inception  of  recovery  is  largely  automatic, 
this  stage  of  amesthesia  is  likely  to  suffer  from  dangerous 
neglect.  The  anaesthetist  is  very  apt  to  feel  that  when  he 
ceases  to  give  ether  his  responsibilit}^  is  at  an  end,  whereas 
his  release  does  not  come  until  consciousness  returns. 

We  may  conveniently  consider  the  evidences,  types  and 
control  of  the  stage  of  recovery. 

A.  The  Evidences  of  the  Stage  of  Reco^t:ry. — 
The  stage  of  recovery  becomes  evident:  («)  in  the  gradual 
and  complete  return  of  the  reflexes;  {b)  in  the  return  of 
consciousness. 


COMPLETE  GENERAL  ANESTHESIA  75 

(a)  One  of  the  first  signs  to  appear,  upon  allowing 
the  patient  to  recover,  is  a  slowing  down  of  the  respira- 
tions. These  will  drop  from  40  to  2.5  or  20  a  minute.  The 
pu^^il,  which  has  been  moderately  dilated  during  the  stage 
of  maintenance,  will  contract.  That  which  has  been  smaller 
than  normal  will  become  pin-point  or  widely  dilated  from 
sympathetic  stinmli.  There  will  be  rolling  of  the  eyeballs, 
also  active  lid  and  corneal  reflexes.  One  may  also  expect  the 
pulse  to  increase  in  rapidity.  Rigidity  will  show  itself  in 
the  masseters  and  in  increased  intra-abdominal  tension. 
The  patient  will  swallow,  and,  shortly  after  this,  retch. 
Vomiting  usually  marks  complete  return  of  reflexes. 

{ h )  Following  the  vomiting,  which  occurs  upon  the  re- 
turn of  the  reflexes,  there  may  be  a  period  of  quiet,  during 
which  time  the  patient  is  slowly  recovering  consciousness. 
If  this  period  of  quiet  does  not  follow  upon  several  attacks 
of  vomiting,  the  j^atient  may  develop  either  protracted  cy- 
anosis and  vomiting,  or  on  the  other  hand,  may  become 
pallid  with  barely  perceptible  pulse  and  shallow  breathing. 

B.  The  Types  of  Reco\try.— The  chief  cause  of  re- 
covery is,  of  course,  the  withdrawal  of  the  angesthetic. 

We  recognize  two  types  of  recovery  ( see  Figs.  52  and 
.53).     («)  recovery  by  crisis ;  {h)  recovery  by  lysis. 

(a)  Recovery  hy  crisis  (Fig.  52)  is  that  type  of  re- 
covery in  which  the  interval  extending  from  the  end  of  the 
stage  of  maintenance  to  the  return  of  consciousness  is  very 
brief.  This  type  of  recovery  is  of  course  most  desirable. 
Instead  of  coming  about  in  the  course  of  hours  it  takes 
place  in  minutes  or  seconds.  The  best  example  of  recover}'- 
by  crisis  is  found  in  gas  oxygen  anaesthesia.  With  this 
ansesthetic  a  patient,  who  has  been  held  in  the  stage  of 
maintenance  for  two  or  three  hours,  will  recover  conscious- 
ness in  as  many  minutes. 


76 


ANESTHESIA 


(b)  Recovery  by  lysis  (Fig.  53)  is  a  common  occur- 
rence in  hospital  anaesthesia  where  the  anaesthetist  uses  a 
high  level  of  maintenance  to  the  end  of  the  operation. 
Patients  who  experience  this  type  of  recovery  may  not 
regain  consciousness  for  four  or  five  hours  after  the  end  of 
the  stage  of  maintenance.  The  most  marked  cases  of  this 
type  of  recovery  are  found  in  diabetic  patients.  Occasion- 
ally these  patients  never  recover  consciousness. 


lO 

Mm. 


20  I  1-5 

MIN.  '"MIN. 

G.   52. — Recovery  by  crisis. 


The  following  factors  tend  to  induce  recovery  by  crisis: 
nitrous  oxide  oxygen  ansesthesia ;  deep,  free,  rapid  respira- 
tions; alcoholism;  a  short  stage  of  maintenance;  the  use  of 
closed  method  with  good  oxygenation  and  employment  of 
rebreathing ;  the  surgeon  who  permits  early  recovery. 

The  following  factors  tend  to  produce  recovery  by  lysis : 
ether  ansesthesia ;  a  long  stage  of  maintenance;  preliminary 
morphine  medication;  acidosis;  shallow  or  obstructed  res- 
j^irations ;  the  use  of  the  closed  method  with  persistent  high 
maintenance  and  cyanosis. 

C.  The  Control  of  the  Stage  of  Recovery. — The 

control  of  the  stage  of  recovery  divides  itself  naturally  into : 

(a)  that  portion  dating  from  the  onset  of  the  stage  to  the 


COMPLETE  GENERAL  ANESTHESIA 


77 


time  when  the  reflexes  have  completely  returned ',  (b)  that 
portion  dating  from  the  complete  return  of  the  reflexes  to 
the  return  of  consciousness. 

We  recognize  these  two  periods  of  recovery  because  this 
division  naturally  comes  about  in  the  treatment  of  the  pa- 
tient. Before  the  reflexes  have  returned  the  patient  is  un- 
der the  immediate  supervision  of  the  anaesthetist.  After 
the  complete  return  of  the  reflexes  he  usually  passes  into 
the  hands  of  the  nurse. 


Recover>'  by  lysis. 


{a)  The  flrst  period  of  the  stage  of  recovery  should 
take  place  in  the  operating  room  on  the  operating  table. 
The  vomiting,  which  accompanies  the  return  of  the  re- 
flexes, should  be  over  by  the  time  the  patient  leaves  the 
operating  room. 

Some  patients  do  not  vomit  upon  the  return  of  the  re- 
flexes, but  the  large  proportion  who  do  not  at  least  retch 
once  or  twice.  It  will  be  understood  that  at  this  time,  con- 
sciousness having  not  yet  returned,  such  retching  and  vom- 
iting are  not  distressing  to  the  patient. 

Our  chief  problem  in  controlling  the  stage  of  recovery 
is  to  determine  when  to  begin.     The  exact  time  at  which 


78  ANESTHESIA 

the  anesthetic  may  be  stopped  is  governed  largely  by  ex- 
perience. This  is  one  of  the  features  which  go  to  make  up 
the  A?'t  of  Ancvsthesia.  Broadly  speaking,  in  the  case  of 
abdominal  operations,  a  moderate  level  of  maintenance 
having  been  carried,  the  anaesthetic  may  be  permanently 
reduced  as  soon  as  the  fascia  is  closed.  When  the  surgeon 
begins  to  sew  up  the  skin  the  face  piece  may  be  removed. 
In  operations  other  than  intra-abdominal,  the  anaesthetic 
may  be  reduced  at  an  earlier  period,  the  index  in  these  cases 
being  the  comfort  and  freedom  of  the  surgeon  from  objec- 
tionable signs,  as  rigidity,  vomiting,  movement,  etc. 

If  the  throat  tube  has  been  in  use  during  the  course  of 
the  operation,  it  should  be  left  in  place  until  retching 
begins.  By  maintaining  a  free  airway,  an  early  recovery 
is  thus  obtained.  If  the  Trendelenburg  position  has  been 
used,  when  the  head  of  the  table  has  been  raised,  a  lessened 
cerebral  circulation  will  result.  If  this  position  be  ex- 
aggerated as  in  the  case  of  upper  abdominal  operations,  the 
pulse  should  be  carefully  observed  for  shock.  The  anaes- 
thetic may  also  be  reduced  and  withdrawn  at  an  earlier 
period.  If  the  induction  has  been  stormy,  and  the  main- 
tenance controlled  with  difficulty,  the  aucesthetist  should 
pay  particular  attention  to  the  patient  during  the  stage  of 
recovery,  for  there  are  likely  to  be  attacks  of  vomiting  ac- 
companied by  masseteric  spasm  and  distressing  cyanosis. 
If  this  trouble  is  anticipated,  the  mouth  tube  should  be  held 
in  place  until  the  reflexes  have  returned  to  such  a  degree 
that  the  active  laryngeal  reflexes  will  not  permit  of  the 
inspiration  of  vomited  material. 

(6)  It  will  readily  be  appreciated  that  the  second  period 
of  recovery  (after  the  reflexes  have  returned)  will  be  in- 
fluenced by  the  fact  that  the  operation  has  been  done  in  the 


COMPLETE  GENERAL  AN^STHESLV  79 

home  instead  of  in  the  hospitaL  In  this  case,  unless  speci- 
ally trained  nurses  be  available,  the  patient  must  be 
watched  carefully  until  consciousness  has  returned.  The 
return  of  consciousness  need  not  consist  of  a  complete 
orientation,  a  clear-cut  appreciation  of  all  that  has  taken 
place.  It  is  sufficient  that  the  patient  answers  questions 
intelligently.  It  is  sufficient  that  she  "has  found  herself," 
so  to  speak.  As  the  patient  approaches  the  amesthetic 
somewhat  confused  by  the  action  of  the  preliminary  mor- 
phine, so  it  is  not  only  permissible  but  advantageous  to 
leave  her  in  some  confusion  regarding  her  condition  and 
somewhat  irresponsive  to  the  pain  which  would  otherwise 
torment  her. 

Ninety-nine  cases  out  of  one  hundred  would  probably 
make  an  uneventful  recovery,  if  abandoned  to  themselves 
after  the  reflexes  have  returned.  The  remainin"-  one  miffht 
die.  Is  it  not  worth  the  possible  saving  of  one  life  in  a 
hundred  cases  to  watch  carefully  the  recovery  of  each?  If 
that  life  was  ours  there  would  be  but  one  answer. 

The  recovery  may  worry  us  either  because  the  patient 
develops  continual  spasm,  cyanosis  and  vomiting,  or,  on 
the  other  hand,  because  of  pallor,  almost  imperceptible 
pulse,  and  a  slow  and  very  shallow  respiration. 

The  first  trouble  is  usually  noticeable  at  once.  In  this 
case  the  wooden  mouth  gag  may  be  introduced,  the  teeth 
separated,  and  tip  of  tongue  pulled  forward  for  a  mo- 
ment by  grasping  it  with  gauze  or  with  an  ordinary  sponge 
forceps.  If  it  is  impossible  to  separate  the  teeth,  or  if  there 
is  not  room  enough  behind  the  last  molar  and  the  ascending 
ramus  of  the  jaw  to  pass  in  the  finger  and  depress  the 
tongue,  then  a  large  catheter,  moistened  with  the  jjatient's 
saliva,  should  be  passed  through  one  of  the  nostrils  by  the 


80 


ANAESTHESIA 


seat  of  obstruction  into  the  larvngopharynx.  Air  is  what 
patient  needs  and  when  it  is  admitted  the  spasifi  will  pass. 
As  the  olfactory  sense  returns,  the  patient,  upon  smell- 
ing her  expirations  laden  with  ether,  will  often  vomit  re- 
flexly.  This  type  of  vomiting  frequently  responds  to 
treatment  designed  to  obscure  the  odor  or  reduce  the  re- 
ceptive powers  of  the  olfactory  mucous  membrane.  A 
piece  of  gauze  moistened  with  vinegar,  essence  of  orange 


FiG.   54. — Gauze  on  upper  lip  moistened  with  essence  of  orange. 

or  some  aromatic  oil,  placed  on  the  upper  lip,  will  often 
produce  the  desired  result  (Fig.  54). 

The  author  recalls  a  recent  case  in  which  this  particular 
form  of  reflex  vomiting  was  relieved  by  inhalations  of  es- 
sence of  orange.  The  jDatient,  a  rather  high-strung  young 
woman,  had  previously  been  twice  anaesthetized  by  ether. 
Her  recovery  and  post-ansesthetic  period  were  character- 
ized by  persistent  and  distressing  vomiting.  Following  a 
subsequent  and  rather  prolonged  ether  anaesthesia  with  a 


COMPLETE  GENERAL  AN^STHESL\  81 

high  level  of  maintenance,  the  patient  gave  signs  of 
recovery  by  crisis.  The  reflexes  returned  rapidly  and  she 
retched  and  threatened  to  vomit.  As  she  hegan  to  retch, 
essence  of  orange  on  a  gauze  wipe  was  jjlaced  over  her  nose 
and  mouth.  The  retching  stopped  at  once  and  did  not  re- 
turn ;  the  subsequent  recovery  was  entirely  tranquil  with  a 
single  brief  attack  of  retching  after  an  interval  of  liours. 

The  second  class  of  j^atients,  those  who  suddenly  de- 
velop imperceptible  pulse  and  very  shallow  respirations 
after  the  return  of  the  reflexes,  act  in  response  to  compli- 
cations which  are  ol)scure  and  difficult  to  meet. 

This  change  usually  comes  suddenly,  following  in  the 
course  of  a  normal  induction  and  maintenance  and  early 
recovery.  It  may  be  seen  in  the  robust  as  well  as  in  the 
delicate.  An  unusually  profound  reaction  to  morphine, 
loss  of  CO:;,  or  a  condition  resembling  ordinary  syncope, 
may  bring  about  this  condition.  Such  patients,  however, 
usually  pass  on  to  an  uneventful  recovery. 

When  the  nurse  is  placed  in  charge  of  the  patient  in  the 
second  stage  of  recovery,  she  should  be  instructed  to  keep 
the  patient  well  blanketed,  to  watch  closely  the  color,  the 
respirations,  and  the  vomiting.  She  should  note  carefully 
the  position  of  the  hot  water  bags,  which  have  been  applied 
to  the  patient.  Continuous  cyanosis,  shallow,  slow  respira- 
tions (10  or  less  per  minute)  should  be  reported  at  once. 
When  vomiting  occurs,  the  patient  should  be  placed  on  her 
side  and  the  head  extended.  If  there  be  pallor,  with  rapid 
running  pulse,  indicating  possibly  internal  hemorrhage,  the 
physician  should  be  summoned  promptly. 

The  sooner  consciousness  returns,  the  better  the  patient 
is  able  to  cope  w4th  his  condition.  Generally  speaking,  we 
may  say  that  recovery  by  crims  argues  well  for  the  final 
and  uncomplicated  surgical  recovery. 

6 


CHAPTER  III 
THE  SIGNS   OF  ANAESTHESIA 

The  signs  of  anaesthesia  may  be  considered  under  five 
headings:  the  respiratorij ;  the  color;  the  muscular;  the  eije; 
and  the  j^ulse. 

During  the  periods  of  excitement  and  rigidity,  we  are 
concerned  chiefly  with  the  first  two,  the  respiration  and  the 
color.  As  anaesthesia  progresses,  the  ilmscular  signs  be- 
come of  value,  later  the  eye  sign  and  lastly  the  pulse. 
During  the  early  periods  of  induction,  the  respiration  and 
the  color  must  be  under  satisfactoiy  control.  The  phe- 
nomena exhibited  by  the  other  groups  at  this  time  are  but 
incidental  and  of  negative  value.  That  is,  they  but  serve 
to  show  us  that  the  patient  is  not  under  the  mfluence  of 
the  anaesthetic.  As  anaesthesia  progresses,  however,  these 
signs  become  of  positive  value  by  assuring  us  that  the 
patient  is  under  the  influence  of  the  anaesthetic  and  in  our 
control. 

1.   THE  RESPIRATORY  SIGNS 

Perhaps  the  most  important  single  sign  of  this  group 
is  the  respiration.  We  should  watch  the  respiration 
closely  from  the  beginning  of  induction  to  the  end  of  re- 
covery. We  should  be  intimately  acquainted  with  the  nor- 
mal respiration  and  be  able  to  detect  any  deviation  from 
the  normal  limits  by  the  sound  alone.  Experience  lends 
one  a  sense  of  safety  which  becomes  so  acute  that  abnor- 
malities grate  upon  the  hearer  and  spur  him  to  relieve  that 

82 


THE  SIGNS  OF  ANESTHESIA  83 

which  he  might  otherwise  suffer  to  persist.  On  the  other 
hand  this  experience  will  also  breed  confidence  and  delib- 
erate action  in  circumstances  which  might  otherwise  ter- 
rify and  lead  to  mani^^ulations,  dangerous  and  injurious 
to  the  patient.  For  example,  a  moderate  but  persistent  de- 
gree of  obstruction  might  be  unnoticed  by  the  beginner, 
while  the  experienced  man,  by  making  use  of  the  throat 
tube,  will  relieve  this  obstruction  and  secure  a  much  de- 
sired relaxation.  On  the  other  hand,  during  the  stage  of 
induction,  the  beginner  may  become  terrified  by  a  duski- 
ness, which  is  not  really  dangerous,  and  break  a  tooth  in 
an  effort  to  relieve  a  spasm,  which  would  otherwise  have 
passed  off  spontaneously  without  active  interference. 

We  may  consider  the  normal  respiratory  phenomena 
by  noting  the  rate  rhythm  and  amplitude,  during  the  stages 
of  induction,  maintenance  and  recovery,  as  exhibited  when 
the  open  and  closed  methods  are  respectively  used. 

The  Normal  Respiration  Under  Ether  When  the 
Open  ^JIethod  is  Used. — When  anaesthesia  is  induced  by 
the  drop  method,  the  respirations  are  at  first  of  normal 
rate,  rhythm  and  amplitude.  As  the  patient  passes  into 
the  period  of  excitement,  the  rate  increases  and  the  rhythm 
remains  constant,  and  the  breathing  becomes  deeper.  As 
anaesthesia  progresses,  the  rate  increases,  the  rhythm  })e- 
comes  slightly  irregular  while  swallowing  and  some  hesita- 
tion is  prone  to  occur.  The  amplitude  will  vary  from  a 
scarcely  noticeable  respiration  to  a  deep,  free  breathing. 
As  the  stage  of  maintenance  is  reached,  the  rate  will  in- 
crease to  35  or  40  respirations  a  minute ;  the  rhythm  will  be 
resumed,  and  the  breathing  will  be  deep  with  a  stertor  of 
varying  intensity.  The  first  incision  will  produce  no  no- 
ticeable effect.     As  maintenance  progresses  the  rate  will 


84  ANiESTHESLl 

continue  constantly  between  40  and  50  a  minute.  The 
rhythm  will  be  occasionally  interrujited  by  gall-bladder 
work,  when  there  will  be  an  eo'piratory  grunt,  and  by  pelvic 
work,  when  there  will  be  an  inspiratory  sighing.  AYhen 
work  is  being  done  on  the  stomach  and  intestines,  the 
rliythm  will  usually  remain  undisturbed.  The  amplitude 
will  have  a  tendency  to  become  less  as  the  stage  of  mainte- 
nance progresses.  The  degree  of  this  shallowness  will  de- 
pend upon  the  extent  to  which  rebreathing  is  permitted 
and  upon  the  integrity  of  the  dia^^hragm.  As  ana?sthesia 
progresses  the  respirations  are  likely  to  become  more  and 
more  shallow,  but  remain  regular  in  rhythm.  The  stage 
of  recovery  having  developed,  the  rate  of  respirations  will 
decrease,  the  rhythm  will  become  halting,  and  the  breathing 
will  become  quite  shallow. 

The  Normal  Respiration  Under  Ether  When  the 
Closed  ^Method  is  Used  and  X-O  is  Employed. — Almost 
immediately  following  the  application  of  the  face  piece, 
the  respirations  will  become  rapid,  regular,  and  much 
deeper  than  normal.  This  is  due  to  the  specific  effect  of 
the  X2O,  creating  what  is  known  as  the  "  besoin  de  respire," 
or  the  necessity  to  breathe.  If  ether  is  now  given  cau- 
tiously, but  with  constantly  increasing  strength,  the  jjatient 
will  shortly  lapse  into  a  stertor.  As  air  is  permitted,  the 
rate  will  fall  somewhat,  but  the  rhythm  will  continue  and 
the  depth  will  be  somewhat  less.  Under  these  conditions 
we  pass  into  the  stage  of  maintenance.  Here  we  will  ex- 
perience differences  due  to  rebreathing  and  dependent  upon 
the  regularity  with  which  our  apparatus  permits  us  to  de- 
liver ether.  If  we  pour  in  a  large  amount  at  long  intervals, 
the  respirations  will  be  slow,  spasmodic  and  shallow  imme- 
diately uj^on  receiving  the  dose,  smoothing  out  as  the  toler- 


THE  SIGNS  OF  ANESTHESIA  85 

ance  is  established.  Small  doses  often  repeated  tend  to 
produce  undisturbed  respirations. 

Briefly,  during  the  stage  of  induction,  when  the  closed 
metJjod  is  used,  the  respirations  are  more  rapid  and  deeper. 
During  maintenance,  less  rhythmical  and  deeper;  during 
recovery,  more  rapid,  regular  and  deeper. 

It  will  be  seen  that  these  variations  from  the  open 
method  are  advantageous,  since  deep  respirations  give  us 
better  control  of  the  patient. 

Respiratory  Abnormalities  Which  are  Likeey  to 
Occur  AVhen  Both  the  Open  and  Closed  Methods 
ARE  Used. — We  may  take  up  separately  the  abnormalities 
occurring  in  induction,  maintenance  and  recovery. 

Abnormalities  which  may  Occur  During  the  Stage  of 
Induction:  Bate. — The  patient  may  scarcely  breathe,  ex- 
cept in  a  very  shallow,  superficial  sort  of  way,  or,  on  the 
other  hand,  the  respirations  may  be  very  rapid.  The  former 
conditions  will  sometimes  occur  in  women  who  have  had 
morphine;  the  latter  will  be  frequently  seen  in  children. 
AVith  a  view  of  securing  a  speedy  induction,  rapid  breath- 
ing will  of  course  be  advantageous.  Slow  breathing  will 
delay  the  completion  of  amTsthesia,  and  frequently  be 
accompanied  by  vomiting.  The  use  of  a  closed  ether 
apparatus  with  a  gas  ether  sequence  usually  overcomes  the 
embarrassment  incident  to  this  type  of  resj^iration. 

Rhytlim.— Unless  care  is  exercised  to  avoid  all  occa- 
sions of  excitement,  especially  over  concentration  of  ether  at 
the  outset,  spasm  of  the  respiration  is  almost  sure  to  occur. 
This  implies  a  respiration  whicli  is  jerky  in  character,  with 
a  varying  degree  of  obstruction.  Such  unsatisfactory 
rhythm  will  automatically  adjust  itself  when  the  obstruc- 
tion is  overcome  and  the  anaesthesia  deepens.     Broadly 


86  ANESTHESIA 

speaking,  true  relaxation  and  satisfactory  maintenance  do 
not  co-exist  with  a  spasmodic,  obstructed  respiration. 

Amplitude. — A  reduction  in  the  necessary  volume  of 
the  respired  air  will  result  in  delayed  induction.  One  of 
the  most  frequent  causes  of  the  patient  not  "  going  under  " 
is  the  lack  of  deep  respirations.  The  tension  or  the  jDcr- 
centage  of  ether  in  the  blood  depends  entirely  upon  the 
amount  which  is  offered  to  the  circulation  at  the  walls  of 
the  pulmonary  alveoli.  If  the  breathing  is  superficial,  the 
ether  enters  only  the  trachea  and  larger  bronchi,  and  must 
depend  entirely  upon  diffusion  to  reach  the  finer  alveoli. 
This  type  of  induction  frequently  occurs  when  the  open 
method  is  used,  and  also  where  the  face  piece  of  the  closed 
apparatus  is  not  in  contact  with  the  face  at  the  bridge  of 
the  nose  and  under  the  cheek.  Such  cases  seem  to  be  going 
along  favorably,  the  breathing  is  quiet  and  the  color  is 
good,  sometimes  a  slight  stertor  is  heard.  As  preparations 
are  made  to  scrub  up,  however,  the  patient  will  suddenly 
make  a  smothered  remark  and  begin  an  active  period  of 
excitement. 

During  the  stage  of  induction  the  patient  must  breathe 
raindly,  rhythmically  and  deeply,  if  the  best  results  are  to 
he  obtained. 

Abnormalities  tvhich  may  Occur  During  the  Stage  of 
Maintenance. — Rate. — When  the  stage  of  maintenance 
has  been  entered  into,  the  rate  of  the  respiration  may  sud- 
denly increase  or  drop  as  the  skin  is  incised  or  the  peri- 
toneum is  opened.  If  this  increase  is  co-existent  with  ab- 
dominal rigidity,  the  level  of  the  anesthesia  must  of  course 
be  raised,  otherwise  a  change  in  rate  may  be  ignored.  This 
sign  is  often  a  valuable  index  to  the  true  depth  of  the  anaes- 
thesia.    If  the  patient  does  not  react  to  these  manipula- 


THE  SIGNS  OF  ANESTHESIA  87 

tions,  he  is  to  be  considered  under  satisfactory  angesthesia, 
even  thougli  the  other  signs  of  Hghtness  may  be  present. 
Excessively  rapid  breathing  occasionally  develops.  When 
the  respiration  increases  to  50  a  minute,  the  anaesthetic 
should  be  stopped,  even  thougii  some  signs  of  lightness 
may  exist.  One  will  usually  find  tliis  rapid  respiration 
co-existing  with  an  absent  corneal  reflex,  dilated  pupil, 
and  muscular  relaxation.  As  a  rule,  withdrawal  of  the 
ana\sthetic  is  quickly  followed  by  a  reduction  in  rate.  Very 
sick  patients,  those  who  are  septic  or  who  have  suffered 
from  hemorrhage,  will  often  react  in  this  manner  in  the 
face  of  a  light  anaesthesia.  If  the  relaxation  b^  satisfactory, 
one  should  always  keep  these  patients  upon  the  lightest 
possible  anaesthesia.  Unusually  slow  respiration  in  the 
presence  of  signs  of  deep  anaesthesia  may  be  due  to  the 
effect  of  morphine  or  too  much  rebreathing.  This  sign 
is  particularly  distressing  because  it  is  so  difficult  to 
treat.  If  occurring  where  the  open  method  is  employed, 
morphine  having  been  used,  the  closed  method  should  be 
resorted  to,  in  the  hope  that  the  accumulated  COo  will  serve 
to  stimulate  the  respiration.  If  following  in  the  course  of 
excessive  rebreathing,  the  condition  may  be  due  to  a  depres- 
sion of  the  respiratory  centre  by  the  use  of  too  much  CO- 
or  to  lack  of  oxygen.  Patients  who  do  not  react  to  re- 
breathing should  be  given  a  hypodermic  of  1/100  gr.  of 
atropine. 

Rhijthm. — The  rhythm  of  the  respiration  during  the 
stage  of  maintenance  is  either  a  source  of  comfort  or  the 
occasion  of  much  anxiety.  Disturbances  of  rhythm  occur- 
ring upon  gall-bladder  or  pelvic  manipulation  are  usually 
reassuring,  as  they  indicate  a  moderate  lightness  of  anes- 
thesia.    Respirations  which  lack  rhythm  from  unknown 


88  ANESTHESIA 

causes  frequently  indicate  deep-lying  trouble.  CerebraJ 
hemorrhage  into  the  base,  pulmonary  embolus  or  overdos- 
ing with  ether  will  often  show  itself  by  such  a  form  of  dis- 
turbance. Occasionally  one  meets  with  Cheyne- Stokes 
respiration.  The  author  recalls  such  a  case,  in  which 
Cheyne- Stokes  respiration  immediately  preceded  a  fatal 
issue. 

Disturbances  of  rhythm  often  occur  where  the  level  of 
the  anaesthetic  has  been  permitted  to  drop,  the  ether  having 
been  partially  or  completely  withdrawn.  In  such  a  case, 
upon  the  reapplication  of  the  mask  into  which  ether  has 
been  poured,  the  respiration  will  become  spasmodic.  If 
the  level  has  been  very  low,  complete  stoppage  may  result, 
followed  by  spasmodic  breathing  until  the  patient  is  once 
again  anesthetized.  If  the  level  is  higher,  the  effect  will  be 
a  temporary  slowing,  followed  by  an  increase  in  rapidity. 

Amplitude. — The  amplitude  of  the  respiration  in  the 
stage  of  maintenance  appears  to  depend  upon  the  action  of 
the  diaphragm  and  the  presence  or  absence  of  COo. 

If  a  closed  method  is  used,  the  breathing  will  be  deeper 
throughout.  If  open,  the  reverse  is  true.  If  the  level  of 
the  maintenance  is  moderate,  50  mm.,  the  action  of  the 
diaphragm  is  vigorous  and  the  respirations  are  deep;  if 
the  level  is  high,  80  mm.,  the  action  of  the  diaphragm  is 
progi'essively  affected  and  the  respiration  is  shallow. 

During  upper  abdominal  operations,  we  must  try  to  les- 
sen the  respiratory  effort  so  that  abdominal  movement  will 
be  reduced  as  much  as  possible.  First  of  all  the  respira- 
tions must  be  unobstructed.  The  consequent  limitation  of 
oxygen  and  the  accumulation  of  CO2  in  these  cases  cause 
embarrassing  movements  of  the  diaphragm.  If  the  res- 
pirations are  as  free  as  possible,  and  the  abdominal  respira- 


THE  SIGNS  OF  ANESTHESIA  89 

tion  is  still  annoying,  we  must  partially  paralyze  the  action 
of  the  diaphragm  by  raising  the  level  of  the  maintenance. 
In  this  connection  we  may  speak  of  the  danger  of  trying 
to  secure  such  relaxation  where  nitrous  ojcide  and  oxygen 
is  the  anaesthetic.  In  this  case  ether  must  be  used.  The 
securing  of  a  higher  level  of  maintenance  in  such  cases 
should  proceed  with  caution  and  in  compliance  with  the 
signs  of  deep  anaesthesia,  as  exhibited  by  the  other  signs 
of  anaesthesia  which  we  have  at  our  command.  The  free 
use  of  oxygen  often  leads  to  decreased  respiratory  efforts 
and  the  desired  result  is  thus  ol)tained.  This  treatment 
should  always  be  followed,  and  when  successful  is  always 
preferable  to  raising  the  level  of  the  anaesthetic.  Occasion- 
ally when  absolute  freedom  of  the  respiration  obtains  and 
no  rebreathing  is  permitted,  the  patient  will  cease  to 
breathe.  This  a23noea  may  continue  for  a  minute  or  two. 
When  enough  CO-  has  accumulated  to  stimulate  a  respira- 
tion, the  patient  will  breathe  spontaneously.  If  cessation 
of  the  respiration  occurs  in  the  presence  of  good  color,  pulse 
and  eye  signs,  which  show  a  moderate  degree  of  antes- 
thesia,  one  need  not  worry,  for  there  must  be  other  signs  of 
depression  before  the  patient  is  really  in  danger. 

The  Trendelenburg  position  often  affects  the  ampli- 
tude of  the  respiration.  This  is  particularly  true  of  large, 
fat  subjects.  A  low  level  of  maintenance  in  these  cases  will 
cause  embarrassing  abdominal  respirations.  A  high  level 
will  be  prone  to  result  in  respirations  which  are  alarmingly 
shallow. 

Abnormalities  in  the  Respiration  which  may  Occur 
During  the  Stage  of  Recovery. — In  the  first  half  of  re- 
covery : 

The  rate  of  the  respiration  during  the  first  half  of  the 


90  ANAESTHESIA 

stage  of  recovery,  that  is,  to  the  complete  return  of  the 
reflexes,  is  subject  to  the  amount  of  manipulation  which 
the  patient  experiences  at  this  period.  In  the  beginning 
of  the  stage  there  is  little  change ;  but  as  the  reflexes  return, 
the  respiration  may  be  increased  or  diminished.  As  the  pa- 
tient suddenly  loses  the  stimulating  effect  of  CO2,  the  res- 
pirations will  drop  in  frequency,  but  as  the  pain  of  the 
stitches  is  felt,  the  respirations  will  again  increase.  Dis- 
turbances in  the  rhythm  and  amplitude  are  subject  to  at- 
tacks of  retching  and  vomiting. 

In  the  second  half  of  recovery:  In  the  second  half  of 
the  stage  of  recovery,  between  the  complete  return  of  the 
reflexes  and  the  return  of  consciousness,  the  rate  may  drop 
to  six  or  eight  respirations  a  minute.  The  rhythm  may  be 
regular  or  may  resemble  Cheyne- Stokes.  The  amplitude 
may  be  either  small  or  large.  Such  cases  may  be  ascribed 
to  a  profound  reaction,  to  morphine  or  to  a  reaction  which 
follows  in  the  course  of  excessive  rebreathing.  One  should 
differentiate  these  two  types  of  cases,  as  the  treatment  for 
one  would  be  the  worst  thing  possible  for  the  other.  The 
depression  of  the  respiration  from  the  use  of  morphine  will 
usually  be  associated  with  a  pin-point  pupil  and  will  have  a 
tendency  to  persist.  Where  a  reaction  to  rebreathing  is 
the  cause,  the  pupil  will  be  normal  or  enlarged  and  the  con- 
dition will  tend  to  pass  off.  When  the  patient  will  not 
breathe  spontaneously,  artificial  respiration  must  be  in- 
duced as  follows: 

Artificial  Respiration. — Artificial  respiration  is  for  the 
purpose  of  intermittently  replacing  the  air  in  the  mouth, 
trachea  and  bronchi.  The  nature  of  this  replacement  must 
approach  the  ideal  offered  by  spontaneous  respiration. 
The  rate,  the  volume,  and  the  pressure  under  which  fresh 


THE  SIGNS  OF  ANESTHESIA  91 

air  finds  its  way  into  the  lungs  are  the  standards  which 
govern  artificial  respiration. 

Respiration  consists  of  two  phases,  inspiration  and  ex- 
piration. We  are  chiefly  concerned  with  inspiration.  Ex- 
piration comes  about  spontaneously  through  the  natural 
resiliency  of  the  structures  involved. 

There  are  two  methods  of  artificial  respiration:  (1) 
negative  ventilation;  (2)  positive  ventilation. 

Normal  respiration  brings  about  negative  ventilation. 
The  ribs  being  raised  and  the  diaphragm  contracted,  the 
cavities  containing  the  lungs  are  enlarged.  Atmospheric 
pressure  within  the  latter  quickly  fills  the  partial  vacuum 
thus  formed.  With  such  normal  respiration  negative  ven- 
tilation is  most  efficient. 

Where  spontaneous  respiration  has  failed,  however, 
artificial  respiration  by  negative  ventilation  can  bring 
about  only  a  partial  inspiration  because  the  diaphragm  has 
ceased  to  act.  The  ribs  may  be  raised  but  the  diaphragm 
cannot  be  lowered  as  in  normal  respiration. 

Negative  ventilation  is  exemplified  by  the  well-known 
method  of  Sylvester,  the  technic  of  which  is  as  follows : 

1.  The  tongue  is  grasped  by  sponge  or  artery  forceps 
and  pulled  well  forward.  This  first  manceuvre  is  abso- 
lutely essential  to  insure  freedom  of  the  airway.  Complete 
extension  of  the  head  over  the  edge  of  the  table  should  be 
practised,  as  shown  in  Figs.  55  and  5Q. 

2.  With  the  patient  lying  flat  on  his  back,  the  head 
well  extended,  the  operator  stands  at  the  head,  grasps  the 
arms  just  above  the  elbows  and  presses  them  firmly  and 
steadily  against  the  sides  of  the  chest  (Fig.  o5).  After  a 
couple  of  seconds  the  arms  are  extended  and  brought  over 
the  patient's  head.     This  act  by  lifting  the  ribs  causes  in- 


92  ANAESTHESIA 

spiration  by  negative  ventilation  (Fig.  56).  These  two 
movements  should  be  repeated  sixteen  to  eighteen  times 
a  minute. 

Artificial  Bespiration  by  Positive  Ventilation. — By 
positive  ventilation  we  endeavor  to  intermittently  distend 
the  lunffs  bv  air  delivered  directly  into  the  trachea  or  into 
the  pharynx.  At  the  time  of  distention  (inspiration)  the 
chest  incidentally  expands.  We  say  incidentally  because 
the  movements  of  the  chest  are  passive;  they  are  only  an 
index  of  the  degree  of  lung  expansion. 

At  the  time  of  distention  the  paralyzed  diaphragm 
sinks,  being  forced  downward  by  the  increased  intrapul- 
monary  pressure.  Expiration  occurs  through  the  return 
of  the  diaphragm  and  the  falling  of  the  ribs. 

The  most  important  single  factor  in  positive  ventila- 
tion is  the  pressure  at  which  the  air  is  thrown  into  the  lungs. 
This  pressure  should  not  exceed  2,5  to  30  mm.  of  mercury. 
If  greater  pressure  is  employed  rupture  of  the  delicate 
air  vesicles  may  result.  Positive  ventilation  may  be  brought 
about  by  intratracheal  insufflation.  The  technic  of  this 
procedure  is  identical  with  that  described  on  page  163  for 
intratracheal  anaesthesia,  the  only  difference  being  that  air 
alone  is  delivered  intermittently  instead  of  constantly.  This 
is  the  most  reliable  method  of  positive  ventilation  and  may 
be  done  by  an  improvised  catheter  or  small  tube,  to  which 
is  attached  an  ordinary  foot  bellows,  and  simple  j^ressure 
gauge. 

A  pressure  gauge  may  be  improvised  by  putting  one 
and  one-half  inches  of  mercury  in  the  wash  bottle  attached 
to  the  oxygen  tank.  The  short  tube  is  left  free,  the  long 
tube  projects  25  mm.  (one  inch)  below  the  surface  of  the 
mercury  and  is  connected  to  the  tube  which  delivers  the 


THE  SIGxXS  OF  AX.ESTHESL\ 


93 


air  from  the  })ellows  to  tlie  patient  (see  Fig.  57).  Any 
pressure  in  this  tube  greater  than  2.5  mm.  or  one  inch  of 
mercury  will  escape  out  of  the  bottle.  If  mercury  is  not 
available,  a  pitcher  or  jar  of  water  1.5  inches  deep  will  do. 
A  tube  projecting  into  this  water  for  a  depth  of  ISy^ 
inches  will  give  the  same  result  since  the  sj^ecific  gravity 
of  mercurv  is  13. .59. 


Fig.   oo. — Sylvester  method  of  artificial  respiration,  first  position. 

Positive  ventilation  by  intrapharyngeal  insufflation  is 
not  quite  so  efficient.  Air  delivered  into  the  pharynx  es- 
capes in  four  directions :  into  the  mouth,  into  the  nose,  into 
the  oesophagus  and  stomach,  and  into  the  trachea.  Every 
exit  but  the  tracheal  must  be  shut  off.  The  mouth  may  be 
closed  by  a  strip  of  adhesive  plaster  fastened  at  one  end 
under  the  chin  and  at  the  other  to  the  forehead.  Escape 
through  the  nose  is  controlled  by  the  presence  of  the  nasal 


94 


ANAESTHESIA 


tubes  (Figs.  83  and  86)  through  which  the  air  is  being 
dehvered.  Accumulation  of  air  in  the  stomach  is  j^revented 
by  placing  a  heavy  weight  (twenty  pounds)  on  the  abdo- 
men and  strapping  this  in  position.  The  operator  may  sit 
on  the  abdomen  if  a  weight  is  not  available.  If  artificial 
respiration  must  be  carried  on  during  a  laparotomy,  a 
stomach  tube  should  be  passed  and  left  in  situ.     This  will 


I'lG.    ,j(>. — Sylvester   method   of   artificial    respiration,  second  position. 

dispose  of  air  which  may  accunmlate  in  the  stomach.  The 
abdomen  being  open  the  operator  may  make  manual  press- 
ure on  the  stomach,  thus  preventing  its  distention. 

Pressure  on  the  abdomen  j^er  se  tends  to  overcome  the 
circulatory  shock  which  is  present. 

In  addition  to  both  negative  and  positive  ventilation, 
inversion  is  frequently  beneficial.  The  patient,  even 
though  full  grown,  is  hung  with  the  head  down  and  swung 


THE  SIGNS  OF  ANESTHESIA 


95 


to  and  fro  for  some  moments.    Such  treatment  by  increas- 
ing tlie  cerebral  circulation  is  often  of  decided  benefit. 

The  "Lewis  Pendulum  Swing"  (Fig.  58)  is  carried 
out  as  follows:  The  patient  should  be  suspended  by  the 
fully  flexed  knees  and  swung  forcibly  from  side  to  side  for 
a  period  of  from  one  to  two  minutes.  Except  with  children, 
it  is  necessary  for  the  operator  to  stand  upon  a  box  or  other 
elevation  sufficiently  high  to  allow  of  a  free  swing.     The 


to 


potient 


-from 
foot  b<2lloyv.s 


Fig.   57. — Simple  form  of  Mercurj-  Manometer. 

suffusion  of  the  neck  and  face,  which  is  brought  on  by  this 
swinging,  is  the  index  by  which  one  may  judge  the  effect  of 
the  centrifugation. 

Recapitulation. — Broadly  speaking,  we  may  say  that 
our  chief  respiratory  difficulties  in  the  stage  of  induction 
are  disturbed  rhythm  and  shallowness.  Stoppage  of  the 
respiration  in  this  stage  is  due  to  obstructed  respiration 
or  acapnia. 

In  maintenance,  disturbances  of  rhythm  and  increased 
rate.  Stoppage  of  the  respiration  in  this  stage  is  due  to 
too  much  ether  or  acapnia. 

In  recovery,  disturbances  of  rhythm  and  reduced  rate. 


96 


ANESTHESIA 


Fig.  58. — Lewds  pendulum  swing. 


Stoppage  of  the  respiration  in  thi.s  stage  is  due  to  obstruc- 
tion of  the  respiration  or  to  the  untoward  effect  of  mor- 
phine. 

Wlien  the  open  drop  method  is  employed,  our  chief 


THE  SIGNS  OF  ANESTHESIA  97 

difficulty  will  be  decreased  amj)litude.  This  will  retard 
induction,  diminish  our  control  of  maintenance  and  delay 
the  recovery. 

When  the  closed  method  is  used,  we  will  be  annoyed  by 
excessive  respiratory  efforts  and,  unless  provision  is  made 
for  constant  small  dosage  as  in  the  case  of  the  closed  drop 
method,  we  will  find  a  frequent  and  embarrassing  change 
in  rhythm.  It  will  also  be  found  that  the  closed  method 
will  obscure  respiratory  sounds,  which  would  be  distinctly 
audible  with  an  open  mask. 

In  order  to  better  appreciate  the  significance  of  abnor- 
malities in  respiration,  it  has  been  suggested  that  the  anes- 
thetist occasionally  try  upon  himself  the  rate  of  rhythm 
and  amjilitude  which  the  patient  exhibits. 

II.  THE  COLOR  SIGNS. 

In  company  with  the  respiration,  the  color  is  one  of  the 
signs  which  becomes  immediately  available  when  ana?sthe- 
sia  is  induced.  AVhile  the  color  necessarily  depends  on  the 
pulse,  yet  in  many  instances  it  is  of  more  value,  and  cer- 
tainly at  all  times  deserves  sej^arate  consideration.  The 
color  sign  is  especially  useful  during  the  stage  of  induction 
when,  generally  speaking,  the  pulse  may  be  entirely  ig- 
nored. During  the  stage  of  itiaintenance  we  are  able  to 
check  up  a  doubtful  duskiness  by  observing  the  color  of 
the  blood  at  the  site  of  the  wound.  Dark  blood  will  call 
for  increased  oxygenation  in  spite  of  an  apparently  good 
color  of  the  lips  and  ears.  It  will  be  observed  that  in  ether 
anaesthesia  even  those  who  have  little  or  no  color  will,  after 
induction,  show  a  very  definite  ever-changing  tint.  This 
color  will  necessarily  be  more  in  evidence  in  the  florid,  full- 
blooded  individual  than  in  the  septic  or  anaemic.     It  will 

7 


98  ANESTHESIA 

vary  from  a  bright  red  through  duskiness,  blueness,  gray- 
ness  and  pallor.  What  color  shall  we  endeavor  to  main- 
tain? The  l)est  color  is  the  normal  color  of  the  patient, 
plus  the  flush  which  is  the  physiological  effect  of  the  ether. 
The  cheeks  and  ears  should  be  pink  and  the  lips  red.  The 
blood  issuing  from  the  wound  should  be  bright.  The  faces, 
necks  and  chests  of  the  full-blooded,  dark-complexioned 
individuals  are  very  likely  to  be  bright  scarlet,  fading  as 
anaesthesia  progresses.  Occasionally  an  erythema  appears, 
which  persists  for  a  short  time.  The  ears  and  lips  of  the 
septic  and  ana?mic  should  be  pink ;  this  will  often  be  accom- 
panied by  a  hectic  flush  of  the  cheeks.  If  the  respiration 
is  normal  and  sufficient  oxygen  is  admitted,  the  color  will 
be  normal.  All  those  factors  which  influence  the  respira- 
tion, as  obstruction,  posture,  etc.,  will  invariably  react  on 
the  color. 

We  may  consider  three  extremes  of  color — bright  red, 
cyanosis  and  pallor. 

Carbon  dioxide,  the  respiratory  stimulant,  may  be  con- 
sidered present  in  redness  and  cyanosis,  where  a  condition 
of  excessive  respiration  or  hypercapnia  exists.  Pallor, 
however,  implies  a  state  of  acapnia  concomitant  with  an  ab- 
sent or  greatly  diminished  respiration.  Incidentalh'^  it  will 
be  well  to  remember  that  the  absence  or  presence  of  carbon 
dioxide  has  nothing  to  do  with  the  cyanosis.  COo  is  pres- 
ent in  the  serum  as  a  complex  acid  and  does  not  enter  into 
union  with  the  hsemoglobin.  It  is  true  that  a  cyanotic 
patient  may  suffer  from  an  excess  of  COo,  but  he  may  like- 
wise suffer  from  a  lack  of  it  and  yet  remain  blue.  Cyano- 
sis has  so  frequently  been  associated  with  conditions  which 
tend  to  accumulate  COo,  that  the  inference  lias  frequently 
been  made  that  the  two  are  identical.    The  practical  appli- 


THE  SIGNS  OF  ANESTHESIA  99 

cation  of  these  facts  may  he  hrought  out  hy  considering, 
for  example,  a  patient  who  is  rehreathing  oxygen  from  a 
hag.  As  he  continues  to  rehreathe  he  will  hecome  saturated 
with  CO2,  hut  his  color  will  remain  unchanged.  On  the 
other  hand,  a  patient  who  is  made  to  ])reathe  to  and  fro 
into  a  hag  containing  atmospheric  air  (the  respirations  in 
their  course  heing  made  to  pass  through  lime  water  which 
will  remove  the  CO2),  will  soon  dispose  of  the  CO2  in  his 
system.  He  will  become  cyanotic  then,  not  from  the  CO^ 
which  has  heen  removed,  but  from  the  lack  of  oxygen. 

When  the  Opex  Method  is  Used. — ^The  color  is 
usually  entirely  satisfactory  during  induction.  As  main- 
tenance  progresses,  however,  the  patient  is  prone  to  de- 
velop acajjnia  from  loss  of  CO2.  More  or  less  pallor  then 
appears  and  persists  through  the  stage  of  recovery.  One 
often  finds  associated  with  this  loss  of  color  a  cold,  perspir- 
ing skin. 

When  the  Closed  Method  is  Used. — During  the 
stage  of  induction,  with  a  closed  method,  using  a  gas-ether 
sequence,  the  patient  while  breathing  the  nitrous  oxide  is 
prone  to  assume  a  dusky  appearance,  which  rapidly  passes 
to  a  marked  cyanosis,  if  the  air  is  excluded. 

Limitation  of  oxygen  during  the  period  of  excitement 
is  thought  to  increase  the  potency  of  the  ether  and  to  hasten 
the  onset  of  maintenance.  The  patient  should  never  be  per- 
mitted to  be  more  than  slightly  dusky.  A  limited  exclusion 
of  air  is  recommended  only  because  its  use  in  sufficient 
quantity,  to  insure  complete  oxygenation,  leads  to  a 
marked  dilution  of  the  strength  of  the  ether  vapor.  Where 
oxygen  may  be  had,  this  difficulty  is  overcome,  and  we  may 
have  perfect  oxygenation  during  this  stage.  Marked  cy- 
anosis will  be  followed  not  only  by  delayed  induction  but 


100  ANESTHESIA 

by  an  increase  in  blood-pressure,  which  is  very  hkely  to  be 
harmful.  When  stertor  has  come  on,  and  while  the  stage 
of  rigidity  still  jJersists,  air  should  be  freely  admitted  and 
rebreathing  encouraged.  Even  though  the  respirations 
seem  satisfactory,  one  should  not  rest  until  the  color  is 
absolutely  satisfactory.  It  will  be  recalled  that  obstruction 
may  occur  in  the  mouth  and  nose,  in  the  pharynx,  in  the 
larynx,  in  the  pulmonary  absorbing  surfaces  and  by  ex- 
ternal pressure  on  all  these  parts.  Persistent  cyanosis  in 
the  presence  of  free  breathing,  with  no  obstruction  in  the 
upper  airwaj^,  would  suggest  an  asthmatic  or  pneumonic 
process  or  possible  cardiac  insufficiency  with  an  accumula- 
tion of  blood  in  the  right  heart.  In  such  a  case  oxygen 
may  be  given  directly  and  efficiently  by  means  of  a  closed 
apparatus. 

During  maintenance,  a  bright-red  color  is  commonly 
associated  with  a  .warm  skin  and  a  profuse  perspiration. 
Such  patients  should  be  carefully  guarded  against 
draughts  which,  by  evaporating  the  surface  moisture,  will 
reduce  the  patient's  temperature.  When  there  is  marked 
hemorrhage  it  is  ^particularly  important  that  a  good  color 
of  the  nmcous  membranes  be  maintained.  Cyanosis  at  this 
time  means  more  to  a  patient  than  it  does  when  there  is  a 
large  amount  of  circulating  blood.  In  this  condition  the 
cheeks  and  ears  become  waxy  in  appearance.  Free  oxygen 
must  be  used  in  these  patients  to  insure  a  good  color. 

In  the  stage  of  maintenance ,  when  the  closed  method  is 
used,  the  control  of  the  color  is  either  not  so  good  or  better 
than  where  the  open  method  is  employed.  This  will  de- 
pend upon  the  ease  with  which  atmospheric  air  or  oxygen 
may  be  admitted  to  the  apparatus.  If  the  rebreathing  is 
hampered  by  gauze  in  too  large  quantities  or  wrongly 


THE  SIGNS  OF  ANAESTHESIA  101 

placed,  it  will  be  found  difficult  to  hold  a  good  color.  If 
the  rebreathing  is  entirely  free  the  stimulation  from  the 
CO2,  by  inducing  a  deeper  respiration,  will  also  afford  a 
means  of  more  easily  oxygenating  the  patient. 

The  surgeon  will  sometimes  remind  us  of  the  color 
index  by  remarking  that  the  blood  is  very  dark  at  the  site 
of  operation.  This  sign  may  also  be  quite  marked  even 
when  the  color  of  the  lips  and  ears  seems  satisfactory. 

In  the  Stage  of  Recovery  when  the  Close d  Method  is 
Used. — During  this  stage  we  may  find  a  tendency  to  pal- 
lor. This,  however,  will  not  be  so  marked  as  when  the  open 
method  has  been  used.  The  presence  or  absence  of  color, 
and  by  color  we  mean  pinkness,  dejjends  upon  the  depth 
of  the  respiration.  A  strong  man  breathing  deeply  may  be 
bright  red,  while  the  same  man  scarcely  breathing  will 
sometimes  appear  waxy. 

Jaundice. — We  often  meet  patients  who  are  intensely 
jaundiced.  It  is  quite  difficult  to  maintain  a  satisfactory 
color  here.  The  mucous  membranes  must  be  depended 
upon  to  show  the  proper  amount  of  oxygenation.  A 
slight  degree  of  cyanosis  will  often  pass  by  unnoticed. 
This  cyanosis,  being  a  sign  of  deeper  trouble,  will  often 
interfere  with  the  smoothness  of  the  anaesthetic.  The 
color  of  the  blood  at  the  site  of  the  wound  will  often  be  our 
best  guide  as  to  the  proper  oxygenation. 

Negroes. — This  race  of  people  shows  a  very  unsatis- 
factory color  index.  Here  again  we  must  depend  upon  the 
color  of  the  lips  and  the  hue  of  the  blood  at  the  site  of  the 
wound.  Pallor  is  sometimes  evident  as  a  clayish  appear- 
ance of  the  skin,  which  may  feel  chilled  and  be  bathed  in 
cold  perspiration.  NoO  and  O  should  not  be  used  upon 
colored  patients  unless  positive  indications  exist,  since  this 


102  ANiESTHESIA 

type  of  anjEsthesia  depends  more  upon  the  color  sign  than 
upon  any  other. 

Briefly  reviewing  we  find  that  the  color  and  the  respira- 
tion go  hand  in  hand.  The  color  may  be  taken  as  an  index 
of  the  efficiency  of  the  respiration;  and  will  serve  to  indi- 
cate the  necessity  or  inadvisability  of  interference.  A  good 
color  is  a  guarantee  of  the  safety  of  the  patient  at  the  par- 
ticular moment  under  consideration.  The  color,  while 
dependent  upon  the  condition  of  the  pulse,  will  neverthe- 
less warn  the  anaesthetist  of  danger  before  a  perceptible 
change  can  be  felt  in  the  rate  or  quality  of  the  latter. 

High  color  or  duskiness  is  often  associated  with  profuse 
perspiration  and  a  warm  skin.  Hemorrhage  and  shock 
become  evident  in  pallor,  and  a  cold  perspiration,  which 
breaks  out  on  the  forehead.  Cyanosis  must  never  be  looked 
upon  with  complacency.  Pallor  concentrates  the  attention 
upon  the  pulse,  which  now  becomes  our  best  guide  as  to 
the  condition  of  the  patient,  and  our  most  reliable  index  as 
to  his  need  of  stimulation. 

III.  THE  MUSCULAR  SIGNS 

We  have  considered  normal  muscular  tone,  rigidity  and 
relaxation.  We  have  tried  to  emphasize  the  causes  and  the 
control  of  each.  The  signs  exhibited  by  the  muscular 
system  depend  for  their  value  upon  a  variable  degree  of 
relaxation.  Three  signs  may  be  easily  observed:  The 
masseteric,  the  lid  and  the  diaphragmatic. 

The  Masseteric  Sign  consists  of  a  relaxation  of  the 
muscles,  which  control  the  lower  jaw,  permitting  the 
mouth  to  be  opened  and  closed  without  resistance.  When 
one  is  in  doubt  as  to  the  general  relaxation  which  obtains 
the  presence  of  relaxation  of  the  lower  jaw  will  almost 


THE  SIGNS  OF  ANAESTHESIA  103 

always  settle  the  question.  Occasionally,  however,  even 
when  complete  relaxation  is  present  elsewhere,  respiratory 
disturbances  will  cause  incomplete  freedom  of  the  lower 
jaw,  when  one  attempts  to  elicit  this  sign.  During  the 
period  of  excitement,  rigidity  and  early  relaxation,  this 
sign  is  of  course  negative.  If  a  "  low  "  level  of  mainte- 
nance is  held,  this  sign  may  not  show  itself  in  its  fulness 
throughout  the  course  of  the  anaesthesia.  During  a  stage 
of  maintenance  suitable  for  abdominal  relaxation,  however, 
it  is  almost  invariably  present.  As  recovery  j^roceeds  one 
will  note  the  relaxation  pass  off,  the  normal  tone  and 
rigidity  of  the  masseters  taking  its  place.  This  disappear- 
ance of  the  relaxation  during  the  stage  of  maintenance  is 
one  of  the  early  indications  that  the  patient  is  recovering 
and  must  be  either  carefully  watched  or  carried  along  at  a 
higher  level. 

Where  short  operations  are  done  for  intra-oral  work 
and  an  incomplete  anesthesia  is  all  that  is  required,  the 
anesthetist  should  begin  his  induction  with  a  mouth  prop 
or  cork  between  the  patient's  teeth,  for  with  such  a  type 
of  anesthesia,  rigidity  of  the  masseters  is  the  rule. 

Relaxation  of  the  Upper  Eyelid. — During  normal 
sleep  the  eyelids,  owing  to  the  tone  of  the  orbicularis  palpe- 
brarum, remain  closed.  In  the  late  part  of  excitement 
and  through  the  period  of  rigidity,  one  will  find  that  if  the 
eyelid  is  lifted  and  then  released,  it  will  fall  back  into  place 
with  more  or  less  snap.    Later  it  will  remain  open. 

The  lid  sign  is  present  when  the  eyelids  on  being  sepa- 
rated remain  separated.  This  sign  should  be  taken  on  each 
side  and  the  most  inactive  lid  taken  as  the  standard.  In  the 
later  periods  of  induction,  when  stertor  has  come  on  and 
one  is  anxious  to  determine  the  exact  condition  of  the  pa- 


104 


ANAESTHESIA 


tient,  this  sign  with  the  masseteric  sign  will  be  found  very 
valuable.  The  lid  reflex  is  usually  described  as  an  eye  sign. 
We  feel,  however,  that  it  relates  more  directly  to  the  mus- 
cular system.  Furthermore  the  signs  of  true  muscular 
relaxation  during  the  stage  of  induction  are  none  too  many 
and  may  well  be  augmented  by  this  addition. 


Fig.   59. — Diagram  showing  normal  move- 
ment of  diaphragm  and  abdominal 
wall  during  inspiration. 


Fig.   60. — Diagram  showing  movements  of 

diaphragm  and  the  abdominal  wall  during 

inspiration,  just  before  a  fatal  issue. 


The  Diaphragmatic  Sign. — This  sign  deals  with  the 
tonus  of  the  diaphragm.  It  is  of  value  when  one  is  obliged 
to  carry  a  high  level  of  maintenance,  as  is  sometimes  the 
case  in  upper  abdominal  operations.  We  base  our  deter- 
minations of  the  relaxation  of  the  dia2Dhragm  upon  the 
character  of  the  abdominal  respirations.    Normally,  when 


THE  SIGNS  OF  AXyESTHESlA  105 

inspiration  takes  place,  the  diapliragin  moves  downward 
upon  the  al)d()niinal  viscera  and  causes  a  (hstention  of  the 
abdomen,  whicli  raises  the  abdominal  wall  (Fig.  .59).  The 
amount  of  the  abdominal  movement  is  greatest  during  the 
period  of  excitement  when  the  movements  of  the  diaphragm 
are  excessive.  As  anesthesia  progi-esses,  these  move- 
ments become  less,  })ut  the  abdomen  still  swells  upon  in- 
spiration. If  the  level  of  the  amesthesia  be  excessively 
raised,  however,  the  diaphragm  relaxes,  and  the  abdomen, 
instead  of  being  distended,  will  sink  during  inspiration 
(Fig.  60) .  This  sinking  in  of  the  abdomen  during  inspira- 
tion is  one  of  the  gravest  danger  signs  and  indicates  that 
anaesthesia  has  been  pushed  beyond  its  legitimate  limit. 
Preceding  this  paralysis  the  breathing  will  become  almost 
entirely  thoracic.  These  are  the  cases  who  have  absolute 
relaxation,  absent  corneal  reflex  and  a  dilated  pupil,  and 
whose  breathing  is  rapid  and  shallow'.  Occasionally  we  are 
obliged  to  "  go  the  limit,"  but  we  should  at  least  understand 
what  constitutes  "  the  limit." 

Our  first  concern  then  is  to  secure  relaxation  of  the 
eyelid  and  lower  jaw.  When  we  have  passed  into  the 
stage  of  maintenance  and  we  know  that  the  patient  is 
deeply  auitsthetized,  we  should  narrowly  observe  the  move- 
ments of  the  abdomen  during  inspiration  until  the  stage  of 
recovery  has  begun. 

IV.    THE  EYE  SIGNS 

The  eye  signs  consist  of  three  groups,  the  lid  signs  the 
globe  signs  and  the  pupillary  signs. 

The  Lid  Reflexes  consist  of  reflex  responses  to  irrita- 
tion of  the  sensitive  conjunctiva  and  cornea.     These  signs 


106  ANAESTHESIA 

are  as  follows:  The  Conjunctivo- Palpebral  Re  flea:,  the 
Corneal  Re  flea?  and  Parsons's  Sign. 

The  ConjuncHvG-Pnlpehral  Reflex  is  the  reflex  which 
causes  the  eyelid  to  close  when  the  tip  of  the  finger,  in  sepa- 
rating the  lids,  gently  brushes  over  the  margin  of  the  upper 
fid.  This  reflex  must  be  differentiated  from  the  lid  reflex, 
which  has  been  described  under  the  muscular  signs,  and 
is  due  to  the  tone  or  the  elasticity  of  the  muscle  which 
moves  the  lid. 

The  Corjieal  Reflex. — This  reflex  is  without  doubt  the 
most  valuable  eye  sign  which  we  have.  It  is  elicited  as 
follows :  Standing  behind  and  above  the  patient,  the  opera- 
tor gently  bathes  the  orbital  conjunctiva  by  moving  the 
upper  lid  over  it  several  times.  He  then  separates  the  lids 
with  his  index  finger.  When  the  lids  have  been  slightly 
separated,  the  index  finger  is  removed  and  the  pulp  of  the 
middle  finger,  moistened  with  vaseline,  is  very  gently 
caused  to  brush  over  the  centre  of  the  cornea.  The  degree 
of  activity,  with  which  the  eyelid  then  closes,  constitutes 
one  of  the  most  unvarying  signs  of  the  depth  of  the  anaes- 
thesia. The  operation  is  concluded  by  again  washing  over 
the  orbit  by  the  upper  lid.  This  particular  sign  and  its 
elicitation  have  been  the  subject  of  much  adverse  criticism. 
It  has  appeared  to  many  a  somewhat  barbarous  practice. 
The  author  once  held  this  view.  Needless  to  say  it  is  not 
a  sign  to  be  used  thoughtlessly  or  roughly.  It  is  a  sign 
which  one  uses  to  corroborate  other  signs.  We  have  yet  to 
see  any  trouble  arising  from  its  use.  Compare  this  very 
mild  form  of  irritation  to  that  too  often  produced  by  a 
piece  of  gauze  placed  over  the  eyes,  to  protect  them  during 
the  course  of  the  anaesthesia.  The  lid  reflex  having  been 
lost,  the  bare  gauze  rubs  constantly  and  harshly  against 


THE  SIGNS  OF  ANAESTHESIA  107 

the  sensitive  cornea.  The  result  is  a  varying  degree  of 
conjunctivitis  or  worse.  We  cannot  hide  our  heads  Hke 
the  ostrich  and  say  that  there  is  no  harm  because  it  is 
not  visible. 

Some  advise  that  the  eye  signs,  or  at  least  the  corneal 
reflex  be  disregarded.  This  may  be  done  if  one  is  not 
particular  as  to  the  exact  condition  of  the  patient  at 
any  given  time.  Such  a  course  would  appear  analogous 
to  one  objecting  to  the  taking  of  a  blood  count  because  of 
the  possible  danger  of  tetanus  from  infection,  caused  by 
the  pin  prick.  The  corneal  reflex  is  without  doubt  the  best 
corroborative  sign  which  we  have  and,  properly  taken,  is 
free  from  danger  or  annoyance  to  the  patient. 

During  the  period  of  excitement  and  rigidity,  the  corneal 
reflex  is  snappy;  as  relaxation  comes  on  the  sharpness  of 
the  reflex  gradually  decreases.  When  maintenance  has  been 
entered  into,  the  reflex  has  either  become  quite  sluggish  or 
is  absent.  The  reappearance  of  the  corneal  reflex  and  its 
variable  activity  during  the  stage  of  maintenance  will  give 
one  a  most  satisfactory  idea  as  to  the  exact  depth  of  the 
ana?sthesia.  When  the  stage  of  maintenance  is  carried  at 
such  a  high  level  that  the  corneal  reflex  has  disappeared, 
its  prompt  return  in  the  first  stage  of  recovery  will  always 
prove  a  great  comfort.  Generally  speaking  we  may  say 
that  a  dangerous  level  of  maintenance  and  an  active  corneal 
reflex  do  not  coexist.  One  should  not  take  this  sign  re- 
peatedly on  the  same  eye,  as  the  sensitiveness  will  rapidly 
diminish.  The  most  active  of  the  two  eyes  should  be  taken 
as  the  standard.  The  use  of  morphine  will  frequently  dull 
this  reflex.  When  NoO  and  O  are  used  without  ether,  one 
will  usually  find  a  snappy  reflex  during  an  entirely  tran- 
quil stage  of  mamtenance.    Unexpected  variations  in  this 


108  ANESTHESIA 

reflex  will  be  found  in  little  children  and  very  sick  patients. 
Again  we  would  urge  that  the  individual  patient  be  caused 
to  form  his  own  index  of  activitj^  and  while  this  sign  is 
most  valuable  ijer  se,  yet  it  should  be  supported  and  sus- 
tained by  other  signs. 

Parsons's  Sign.—T^hh  consists  of  a  retraction  of  the 
lower  lid  towards  the  internal  canthus,  when  the  carti- 
laginous rim  of  the  upper  lid  is  pressed  against  the  cornea 
immediately  over  the  jDupil.  The  degree  to  which  the  re- 
traction of  the  lower  lid  takes  place  indicates  the  depth  of 
the  ana?sthesia. 

The  Orbital  Signs. — The  presence  or  absence  of  move- 
ments of  the  eyeball  during  anaesthesia  will  often  be  found 
of  value.  As  a  sign  purposeful  movements  will  usually 
be  recognized  by  the  peculiar  look  of  animation  and  expres- 
sion. When  these  intelligent,  calculating  eyes  look  at  us, 
we  are  likely  to  feel  apologetic  and  to  cover  them  over  with 
gauze  or  a  towel.  When  consciousness  is  lost,  however,  and 
the  period  of  excitement  or  rigidity  is  well  developed,  we 
find  that  the  eyeballs  are  fixed  or  that  there  is  a  slow  move- 
ment from  side  to  side.  Movements  of  the  eyeball  from 
side  to  side  are  almost  always  a  sign  of  light  anaesthesia. 
We  will  be  very  likely  to  find  such  movements  in  the  period 
of  excitement,  rigidity  and  early  relaxation.  During  ordi- 
nary maintenance  movement  is  absent,  but  it  may  occur 
when  a  very  low  level  is  carried.  During  the  stage  of 
recovery  this  sign  will  usually  be  found  strongly  in  evi- 
dence and  a  precursor  of  approaching  consciousness.  Dur- 
ing the  stage  of  inaintenance,  when  NoO  and  O  are  the 
ansesthetic,  the  eyes  will  often  be  found  looking  fixedly 
downward.  When  ether  is  used,  they  are  usually  fixed 
centrallv. 


THE  SIGNS  OF  ANAESTHESIA 


109 


Generally  speaking,  we  may  say  that  when  the  eyes  are 
stationary,  looking  either  downward  or  straight  forward, 
loss  of  consciousness  is  certain,  and  usually  induction  is 
nearing  conclusion,  or  maintenance  has  heen  entered  upon. 

The  Pupillary  Signs. — Let  us  first  consider  briefly  the 
physiology  of  the  jnipillary  changes  which  may  appear. 
We  must  explain  three  reactions:  Dilation  of  the  pupil; 
contraction  of  the  pupil,  and  the  reaction  to  light. 


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FlQ.  61. — Diagram  showing  enervation  of  the  dilator  and  sphincter  pupillae.      Modified  from 

Howell's  physiology. 

Fig.  61  will  show  clearly  the  mechanism  with  which 
we  have  to  deal. 

Txm)  sets  of  nmscles. — The  dilator  pupiike  and  the 
sphincter  pupilla?. 

Txico  nervous  systems — The  sy  in  pathetic,  which  sup- 
plies the  long  ciliary  nerves  to  the  dilators,  and  the  central, 
which  suj^plies  the  short  ciliary  nerves  to  the  sphincter 
muscles. 

Two  general  conditions,  which  effect  this  mechanism — 
Stimulation  and  paralysis. 


110  ANiESTHESIA 

Stimulation. — The  pupil  dilates  when  the  sympathetic 
system  is  stimulated.  The  pupil  contracts  when  the  cen- 
tral system  is  stinmlated  by  light  ( afferent  impulses  travel 
by  retime  and  optic  nerve;  efferent  by  third  cranial  and 
short  ciliary). 

Paralysis. — When  the  sympathetic  system  is  paralyzed, 
the  pupil  contracts  by  virtue  of  the  tone  of  the  sphincters, 
aided  by  the  engorgement  of  the  ciliary  blood-vessels. 
When  the  central  system  is  paralyzed,  the  pupil  dilates  by 
virtue  of  the  elasticity  of  the  elastic  fibres  of  the  pupil  and 
by  the  emptying  of  the  ciliary  blood-vessels,  which  permit 
the  lens  to  bulge  forward. 

The  understanding  of  these  simple  mechanics  will  en- 
able one  to  anticipate  the  signs  which  may  be  expected  in 
the  various  stages  of  anaesthesia. 

The  Pupillary  Signs  in  Induction,  Maintenance 
AND  Recovery 

Indiiction. — During  the  periods  of  excitement  and  rig- 
idity, the  sympathetic  system  is  everywhere  stimulated, 
consequently  the  pupils  at  this  time  are  usually  dilated. 
The  amount  of  this  dilatation  will  depend  upon  the  excita- 
bility of  the  sympathetic  system  at  the  time  under  con- 
sideration. If  there  is  a  greatly  reduced  irritability,  as 
where  morphine  has  been  given  before  operation,  this  dila- 
tation may  be  very  brief  and  occasionally  absent  altogether. 
As  the  period  of  relaxation  comes  on,  the  sympathetic  sys- 
tem will  become  paralyzed  and  the  pupil  will  contract. 
The  central  system  being  intact,  however,  the  reflex  to 
light  will  remain. 

Maintenance. — The  exact  condition  of  the  pupil  in  the 
stage  of  maintenance  will  vary  according  to  the  degree  to 


THE  SIGNS  OF  ANESTHESIA  111 

which  the  sympathetic  system  is  ana?sthetized.  If  only 
partly,  there  will  be  moderate  transient  dilatation  upon 
pain  stimuli.  If  dee^^ly,  the  pujjil  will  be  smaller  than 
normal  and  show  little  or  no  reaction  to  sympathetic 
stimuli.  Movements  of  the  margin  of  the  pupil,  more  or 
less  rhythmical  in  character,  may  show  themselves  when 
pelvic  or  gall-bladder  stimuli  are  apjjlied.  When  the  pupil 
is  contracted,  the  reflex  to  light  will  vary  with  the  irrita- 
bility of  the  central  nervous  system  or  the  level  of  mainte- 
nance. If  the  ana\sthesia  is  now  pushed,  the  pupil  will  dilate 
by  virtue  of  the  paralysis  of  the  central  nervous  system. 
Since  the  light  reflex  depends  upon  the  integrity  of  the  same, 
this  reflex  will  likewise  be  lost.  The  corneal  reflex  will 
have  disappeared  and  other  signs  of  complete  aucBsthesia 
will  manifest  themselves.  However  clear  this  condition 
may  appear  upon  theoretical  consideration,  it  is  often 
rather  puzzling,  especially  to  the  beginner,  to  determine 
whether  a  dilated  pupil  is  a  sympathetic  dilatation  of  light 
anaesthesia  or  a  paralysis  of  profound  ansesthesia.  The  fol- 
lowing test  should  always  be  made  where  doubt  exists : 

Stop  the  ancesthetic  completely  and  give  air.  If,  after 
a  few  moments,  the  pupil  contracts  (from  shallowness  of 
the  ansesthesia ) ,  then  the  dilatation  was  that  of  profound 
anaesthesia  or  dilatation  of  paralysis.  The  eye  in  this  case 
is  usually  dry  and  lusterless  from  an  inhibited  lacrimation. 

If,  on  the  other  hand,  the  pupil  remains  unchanged  in 
the  face  of  shallower  ancesthesia,  the  dilatation  was  caused 
by  sympathetic  stimidation  and  took  place  because  the 
ancesthesia  was  incomplete.  The  eye  in  this  case  is  usually 
moist,  the  lacrimation  being  abundant. 

Occasionally  one  finds  a  patient  who  is  morphinized, 
or  who,  for  some  unknown  reason,  loses  his  corneal  reflex 


112  ANESTHESIA 

early,  having  a  persistently  dilated  pupil,  which  cannot  be 
reconciled  with  other  signs.  In  such  a  case  it  is  always 
wiser  to  give  the  patient  the  })enefit  of  the  doubt  and  to 
permit  him  to  drop  to  a  lower  level  of  maintenmice  or  to 
"  come  out." 

If  moderate  dilatation  is  present  with  an  active  light 
reflex,  we  may  conclude  that  this  dilatation  is  not  the  dila- 
tation of  paralysis,  but  that  the  patient  is  safe.  The  most 
satisfactory  condition  of  the  ])u\)\\  during  the  stage  of 
maintenance  is  when  it  is  moderately  contracted  and  re- 
sponds to  light. 

Recovery. — During  the  stage  of  recovery,  the  condition 
of  the  pupil  will  again  vary,  dej^ending  upon  the  respective 
action  of  the  various  stimuli  applied  to  the  central  or  sym- 
pathetic system.  As  a  rule  the  action  of  the  latter  is  more 
pronounced,  and  consequently  the  pupil  usually  dilates. 
This  is  particularly  true  when  the  patient  is  about  to  vomit. 
Where  morphine  has  been  used  and  the  recovery  is  entirely 
tranquil,  the  pupil  may  become  pinpoint.  The  light  reflex 
is  present  and  becomes  more  and  more  active  as  the  patient 
recovers. 

In  recapitulating  we  find  that  the  eye  signs  are  divided 
into  the  hd,  the  orbital  and  the  pupillary  signs.  The  pres- 
ence of  the  conjunctivo-palpebral  reflexes  means  a  shallow 
anaesthesia,  its  absence  a  moderate  height.  The  presence 
of  the  corneal  reflex  depends  upon  its  activity.  Its  absence 
almost  invariably  indicates  a  complete  anaesthesia.  When 
the  eyeballs  move  the  patient  is  light.  When  they  are 
fixed,  either  looking  forward  or  downward,  the  patient  has 
certainly  lost  consciousness,  and  is  probably  well  anses- 
thetized.  A  dilated  pupil  with  moist  eyeball,  which  does 
not  contract  when  the  anaesthesia  is  withdrawn,  with  an 


THE  SIGNS  OF  ANESTHESIA  113 

active  corneal  and  light  reflex,  means  shallow  anaesthesia. 
A  dilated  pupil  with  a  lusterless  eyeball,  with  an  absent 
light  reflex  and  corneal  reflex,  which  contracts  when  the 
anesthetic  is  withdrawn,  means  profound  anaesthesia,  or  a 
high  level  of  maintenance.  A  contracted  pupil  with  an 
active  light  reflex  is  a  safe  sign. 

A  contracted  pupil  without  light  reflex  indicates  mor- 
phinism and  may  suddenly  be  followed  by  a  marked  para- 
lytic dilatation.  The  total  absence  of  the  light  reflex 
independent  of  the  size  of  the  pupil  implies  interference 
with  the  central  nervous  system,  usually  a  profound  anaes- 
thesia. By  this  we  mean  the  reaction  to  a  strong  light,  not 
the  ordinary  daylight. 

From  the  foregoing  it  is  therefore  clear  that  one  ex- 
amines the  orbit  for  motion,  the  pupil  for  size  and  for  light, 
and  lastly  the  cornea  for  lid  activity. 

V.    THE  PULSE  SIGNS 

The  pulse  is  an  index  of  the  operative  condition  of  the 
patient.  One  should  note  its  rate,  its  rhythm  and,  most 
important,  its  volume.  During  the  period  of  excitement 
and  rigidity  the  pulse  will  be  of  little  value  as  a  sign. 
As  relaxation  becomes  complete,  however,  and  the  stage  of 
maintenance  is  begun,  we  should  observe  it  carefully. 
When  the  radial  artery  is  not  accessible,  as  it  seldom  is,  then 
we  should  locate  the  temporal  on  the  side  most  convenient, 
palpating  it  with  the  pulp  of  the  middle  finger.  If  we 
palpate  the  same  artery  in  the  same  location  with  the  same 
finger  throughout  the  anaesthesia,  Ave  will  form  concepts  of 
small  variations  in  quality,  which  would  otherwise  be  passed 
over. 

Rhythm  is  normally  constant.    The  skipping  of  beats, 


114  ANESTHESIA 

when  occurring  frequently,  is  a  danger  signal  and  should 
be  reported  to  the  surgeon.  This  is  more  particularly  true 
when  the  pulse  has  been  regular  during  the  early  stages 
of  the  operation. 

The  rate  and  volume  must  be  considered  together.  The 
pulse  rate  will  often  soar  from  pain  stimuli  or  some  deep 
reflex.  Certain  types  of  cases  such  as,  for  example,  exoph- 
thalmic goitre,  will  have  an  exceedingly  rapid  pulse.  If  the 
volume  is  maintained  there  is  not  much  ground  for  anxiety ; 
if,  however,  the  volume  falls  through  hemorrhage  or  shock, 
the  operator  must  be  informed.  Generally  speaking,  the 
surgeon  should  be  notified  when  the  patient  consistently 
runs  a  pulse  of  140  or  over.  If,  in  addition  to  an  increase 
in  rate,  the  pulse  becomes  small  and  rather  difficult  to  pal- 
pate, jjreparation  should  be  made  for  the  administration 
of  saline  solution.  This  is  the  first  and  best  treatment  for 
such  conditions.  One  of  the  easiest  ways  to  give  saline  is 
to  pour  it  directly  into  the  abdominal  cavity.  The  most 
direct  and  effective  method,  however,  is  to  give  an  intra- 
venous injection  into  the  median  basilic  vein  of  either  fore- 
arm (Fig.  62  and  63)  ;  the  technic  of  this  is  as  follows: 

{a)  Tie  a  tourniquet  (bandage)  about  the  arm  above 
the  elbow \  {h)  paint  the  bend  of  the  elbow  with  iodine ;  ( c) 
find  the  vein  if  possible.  If  it  cannot  be  found,  cut  down 
to  where  it  should  be.  When  it  is  found,  dissect  it  free  for 
about  an  inch. 

Tie  a  ligature  below  ( distal )  and  place  an  untied  liga- 
ture above  (proximal)  ;  nick  the  vein  with  a  scissors.  See 
that  the  saline  runs  freely  through  the  cannula  and  that 
the  latter  is  free  from  bubbles.  With  the  saline  flotcing, 
insert  the  cannula  into  the  proximal  end  of  the  vein ;  tie  in 
place  with  one  knot.    With  the  saline  elevated  about  four 


THE  SIGNS  OF  ANESTHESIA 


115 


feet  above  the  vein  and  the  tourniquet  about  the  arm  re- 
moved, let  the  solution  flow  slowly.  The  amount  given 
should  vary  witli  the  needs  of  the  patient;  from  .500  to  1.300 


Fig.  62. — Intravenous  admimstration  of  saline:  nicking  vein.   (Annals  of  Surger>M 

cc.  will  usually  be  found  sufficient.  If  too  much  fluid  is 
admitted  there  will  be  increased  pressure  upon  the  right 
heart,  which  may  suddenly  dilate.  The  volume  of  the  pulse 
should  be  watched,  and  when  its  character  has  improved 


116 


ANESTHESIA 


p: 


Fig.  63.  —  intravenous  administration  of  saline;  cjinnula  tied  in  proximal  end  of 
vein.     (AnnaLs  of  Surgery.; 


THE  SIGNS  OF  ANESTHESIA  117 

sufficiently,  the  flow  should  he  stoj^ped.  The  cannula  is 
withdrawn  and  the  vein  securely  tied.  The  skin  is  then 
sewed  with  silk  or  linen  and  a  sterile  handage  applied. 
Needless  to  say  this  operation  should  he  completed  with 
despatch.  If  the  pulse  has  heconie  very  small,  rapid,  or 
imperceptil)le  hefore  the  saline  is  given,  it  is  well  to  give 
immediately  strychnine  gr.  l/3()  or  camphor  in  oil  gr.  2. 

While  this  treatment  is  taking  place,  the  patient  should 
be  as  as  lightly  anjusthetized  as  possible.  The  indications 
here  are  to  give  enough  anaesthetic,  and  only  enough,  to  keep 
him  quiet.  Oxygen  may  be  resorted  to  with  advantage  and 
rebreathing  is  beneficial.  Cases  which  receive  rebreathing 
with  oxygen  will  be  much  })etter  off  than  those  who  are  held 
by  the  open  drop  method.  The  author  has  frequently 
carried  jDulseless  patients  for  more  than  an  hour  rebreath- 
ing oxygen  and  just  enough  N-O  to  control  undesirable 
movement.  The  full  retarded  pulse  following  a  saline  is 
often  misleading,  as  it  is  artificial  and  will  soon  lose  its 
quality.  It  behooves  one  to  get  the  patient  to  bed  as  soon  as 
possible.  If  the  operative  procedure  is  such  that  the  patient 
cannot  be  moved,  and  if  the  pulse  loses  its  quality  and  once 
more  becomes  rapid,  the  saline  may  be  repeated  in  the  other 
arm.  The  condition  of  such  a  patient  is  desperate  and  his 
response  to  strychnine  and  camphor  will  be  unsatisfactory. 

Where  it  is  inadvisable  or  impossible  to  give  an  intra- 
venous injection,  the  fluid  may  be  given  by  hypodermocly- 
sis,  under  the  loose  tissues  of  the  breast  (Fig.  64),  which 
method  is  very  satisfactory.  The  Trendelenburg  position 
will  improve  the  pulse ;  the  opposite  will  weaken  it. 

Sudden  stoppage  of  the  heart  is  fortunately  rare  with 
ether;  such  a  condition  not  responding  to  artificial  respira- 
tion may  be  handled  by  the  method  described  by  Abrams. 


118 


ANESTHESIA 


Fig.    1)4.    Hypuduri.iorl>  .-is 


THE  SIGNS  OF  ANAESTHESIA  119 

This  is  called  Kuatzu  or  the  Japanese  method  of  restoring 
life,  and  is  a  definite  method  of  resuscitation  used  by 
jiu-jitsu  adepts.  The  patient  is  placed  in  the  prone 
position  with  arms  extended  sideways;  the  operator  with 
his  wrist  lands  severely  on  the  seventh  cervical  vertebra 
with  the  regularity  of  a  carpenter  wielding  a  hammer. 
This  stimulation  is  thought  to  act  by  overcoming  the  vagus 
inhibition  responsible  for  the  cessation  of  the  heart's  action. 
The  hypodermic  injection  of  1  100  gr.  of  atropine 
directly  in  the  heart  has  been  suggested  and  found  valuable 
in  some  cases.  Direct  massage  of  the  heart,  when  the 
abdomen  is  open,  will  also  prove  beneficial  at  times. 


CHAPTER  IV 

ETHER  ANESTHESIA 
GENERAL  CONSIDERATIONS 

Ether,  sulphuric  ether,  ethyl  oxide  or  vinous  ether  is 
a  very  volatile  fluid  possessed  of  a  suffocating  odor  and  a 
bitter  taste.  It  is  colorless,  about  two  and  one  half  times  as 
heavy  as  air  and  boils  at  body  temperature.  Ether  is  very 
inflammable  and  should  be  cautiously  employed  in  the 
presence  of  an  open  flame,  red-hot  cautery  and  the  like. 
Ether  vaj)or,  when  allowed  to  escape  from  a  container,  falls 
until  it  comes  in  contact  with  the  floor,  operating  table  or 
body  of  the  patient.  It  then  travels  in  a  thin  layer  close 
to  the  surface  with  which  it  is  in  contact  until  it  is  dissipated 
in  the  air.  A  flame  or  hot  cautery  which  is  brought  within 
two  inches  of  such  a  surface  will  cause  the  ether  to  burst 
into  flame.  This  may  happen  in  the  cauterization  of 
hemorrhoids  for  example.  The  smoother  the  surface  along 
which  the  ether  travels  the  more  likely  it  is  to  retain  its 
concentration  and  ignite.  Water  has  practically  no  effect 
on  burning  ether.  If  carelessly  applied  it  may  scatter  the 
fire  thereby  increasing  the  danger.  Ether-soaked  gauze 
or  free  ether  which  has  caught  fire  should  be  carefully  and 
systematically  smothered  by  the  use  of  blankets,  towels, 
etc.,  beginning  at  the  patient's  face. 

Etlier  is  commonly  prepared  as  follows :  Ethyl  alcohol 
reacts  with  sulphuric  acid  to  form  ethyl  sulphuric  acid  and 
water.  In  the  presence  of  an  excess  of  alcohol,  ether  is 
formed  and  sulphuric  acid  is  reformed  as  a  residue.  This 
is  known  as  the  continuous  etherification  process.    Ether, 

120 


ETHER  ANAESTHESIA  121 

which  has  heen  exposed  to  air  and  Hght,  should  not  he  used 
for  anti'stliesia,  as  the  irritation  of  products  formed  by 
oxidation  may  prove  injurious  to  the  patient.  Ether  for 
ana?sthesia  is  ordinarily  sold  in  one-quarter  pound  and  one- 
half  pound  sealed  cans.  The  smaller-size  cans  are  prefera- 
ble because  there  is  less  likelihood  of  stale  ether  being 
carried  over  to  the  next  case. 

A  brief  consideration  of  the  discovery  of  ether  will  be 
found  in  the  Introduction.  The  various  methods  of  admin- 
istering ether  have  been  taken  up  in  Chapter  IV.  The 
signs  of  ether  anaesthesia  are  discussed  in  Chapter  III. 
A  classification  of  the  stages  of  ether  anaesthesia  has  been 
suggested  in  Chapters  I  and  II.  The  post-operative  treat- 
ment of  a  case  anaesthetized  by  ether  will  be  found  in 
Chapter  XV,  page  285. 

I.    ADMINISTRATION  OF  ETHER  BY  ORAL 
INSUFFLATION 

By  oral  insufflation  we  mean  the  substitution  of  ether 
va23or  for  the  atmosphere  which  the  patient  ordinarily 
breathes.     ( See  page  9) . 

This  ether  vapor  may  be  presented  to  the  jjatient  in  a 
great  variety  of  ways.  Anything  from  a  gauze  handker- 
chief to  an  expensive  nickel-plated  apparatus  will  accom- 
plish the  desired  result.  While  we  may  in  an  emergency 
ffet  along  with  a  handkerchief,  we  do  not  do  so  from  choice, 
but  from  necessity,  as  such  a  method  is  least  efficient  and 
most  wasteful. 

We  recognize  two  methods  of  administering  ether  by 
the  method  of  oral  insufflation: 

1.  The  %7/i^  method. 

2.  The  vapor  method. 


122  ANESTHESIA 

By  the  liquid  method  we  mean  that  method  in  which 
we  present  liquid  ether  to  the  patient  upon  a  medium  suita- 
ble for  its  speedy  evaporation  by  the  respiration.  In 
this  method  we  depend  largely  upon  the  patient  to  vapor- 
ize the  ether. 

By  the  vapor  method  we  mean  that  method  in  which 
the  ether  is  presented  to  the  patient  already  vaporized.  In 
this  method  the  patient's  respiration  has  nothing  to  do  with 
the  rate  or  the  amount  of  the  evaporation. 

The  liquid  method  is  best  exemplified  by  the  well- 
known  drop  method.  There  are  three  distinct  types  of 
drop  method:  Open,  Semi-open  and  Closed. 

The  Open  Drop  Method 

Apparatus. — The  essential  elements  of  the  apparatus 
are  as  follows: 

(rt)  A  wire  skeleton  face  piece  of  substantial  construc- 
tion, having  a  smooth  surface  for  contact  with  the  pa- 
tient's face;  {b)  covering  for  the  face  piece,  consisting  of 
stockinet  bandage  or  gauze;  (c)  provision  for  the  supply 
of  ether  in  large,  clean  droj^s. 

The  Face  Piece. — One  of  the  most  widely  used  and 
satisfactory  drop  masks  is  that  of  the  Yankauer  pattern 
(Fig.  65).' 

This  fits  the  face  well,  presents  a  smooth  surface  in 
contact  with  the  skin  and  is  substantiallj'  built. 

The  Covering. — One  of  the  best  materials  for  an  open 
drop  evaporation  surface  is  that  afforded  by  stockinet 
bandage.  The  spring  ring,  which  holds  the  covering,  is 
slipped  into  a  six-inch  section  of  the  bandage  and  forced 
down  over  the  wire  frame.  Stockinet  bandage,  being  more 
closely  woven  than  gauze,  gives  a  more  satisfactory  evap- 


ETHER  ANAESTHESIA 


123 


orating  surface.  When  gauze  is  used,  between  ten  and 
twelve  thicknesses  should  be  employed. 

The  Drop  Bottle. — To  obtain  the  best  results  one 
should  have  a  device  which  will  give  large  drops,  the 
rapidity  of  which  may  be  varied  at  will. 

We  speak  of  clean  drops  in  contradistinction  to  the 
drizzle  which  one  will  obtain  from  a  fraved  bit  of  "auze. 
The  anaesthesia  resulting  from  such  a  drizzle  or  spray 


FiQ.  65. — Yankauer-Gwathmey  Drop  and  Vapor  Mask. 

method  is  not  nearly  as  smooth  as  that  obtainable  by  a 
clean  drop.  The  best  drop  bottle  is  prepared  as  follows 
(Fig.  QQ)  : 

Cut  the  lead  cap  neatly  out  of  the  ether  can.  Take  the 
ether  can  cork  and  cut  two  deep  grooves  in  the  sides.  In 
one  of  the  grooves  place  a  little  wick  of  cotton  (not  gauze)  ; 
leave  the  other  groove  free  for  the  admission  of  air.  Place 
the  cork  with  the  cotton  wick  in  the  can ;  allow  the  wick  to 
become  soaked  with  ether,  which  will  drizzle  off  the  frayed 
end.  With  a  pair  of  scissors,  cut  the  wet  wick  so  that  the 
end  is  square  instead  of  frayed.  A  large,  clean  drop,  whose 
rapidity  is  easily  controlled,  is  then  obtained.  An  emer- 
gency drop  bottle  may  be  provided  by  making  a  single 
pinhole  in  the  centre  of  the  lead  cap  in  a  can  of  ether,  which 


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ANAESTHESIA 


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ETHER  ANAESTHESIA  125 

has  not  been  ojjened.  If  the  ean  is  now  grasped  in  the 
pahn  of  the  liand,  the  rise  in  temperature  resulting  will 
cause  the  ether  to  spray  out  when  the  can  is  inverted.  A 
drop  may  then  be  secured  by  controlling  the  spray  with 
the  finger  tip. 

The  Administration. — When  the  open  drop  method  is 
employed,  ether,  as  a  rule,  is  the  sole  ana\sthetic  employed. 
One  may  sometimes  render  the  induction  more  pleasant 
for  the  patient  by  dropping  upon  the  mask  a  little  essence 
of  orange,  wdntergreen  or  some  pungent  essential  oil, 
before  the  ether  is  given.  This  occasionally  serves  to  mask 
the  disagreeable  odor.  The  trick  of  a  smooth  induction, 
however,  consists  in  two  things:  First,  in  causing  the  pa- 
tient to  breathe  somewhat  more  frequently  and  deeply  than 
normal.  Secondly,  in  the  control  of  the  drop  so  that  there 
wall  be  no  spasm  of  the  respiration.  One  of  the  best 
methods  of  controlling  the  respiration  is  to  ask  the  patient 
to  count  slowly  and  loudly.  This  requires  a  certain  atten- 
tion and  decidedly  increases  the  tidal  volume.  In  addition 
to  this,  the  patient  will  give  evidences  of  disturbed  cere- 
bration, which  will  indicate  the  progress  of  the  induction. 
Most  patients  cannot  count  slowly  and  loudly  for  more 
than  one  hundred.  We  increase  the  drop  as  rapidly  as 
w^e  can  and  "  let  up  "  if  the  patient  catches  his  breath.  If 
this  method  is  pursued,  the  patient  w^ill  rapidly  develojj 
a  tolerance,  and  by  the  time  he  has  ceased  to  count  he  will 
be  accepting  without  spasm  an  amount  of  ether  which 
almost  or  entirely  saturates  the  mask.  When  such  an  in- 
duction is  brought  about,  the  rule  is — no  excitement  oc- 
curs, rigidity  is  slight  and  transient,  and  relaxation  comes 
on  slowly  but  completely.  The  respirations  become  ster- 
torous, the  lid  reflex  disappears,  the  jaw  relaxes,  the  eye- 


126  ANiESTHESIA 

balls  become  fixed,  the  pupils  contract  and  the  corneal 
reflex  becomes  sluggish,  indicating  the  onset  of  the  stage  of 
maintenance. 

Maintenance  is  best  controlled  by  a  constant  drop, 
which  may  be  increased  or  diminished  according  to  a  de- 
mand for  a  high  or  low  level  of  anaesthesia.  If  the  anaes- 
thetist becomes  weary  or  loses  interest  during  tliis  stage, 
he  will  very  likely  change  the  drop  into  a  spray  or  j^our 
method.  This  will  surely  result  in  an  uneven  anaesthesia. 
The  best  results  can  only  be  had  by  employing  a  constant 
drop.  As  maintenance  progresses,  the  color  will  fade,  the 
patient  will  lose  surface  temperature  and  the  respirations 
will  become  quite  shallow  from  excessive  ventilation. 
Since  little  ether  is  lost,  little  will  be  needed  to  hold  a  con- 
stant level  of  maintenance.  In  some  cases  relaxation  will 
be  difficult  to  secure ;  but  in  cases  where  it  has  become  com- 
plete, it  will  have  a  tendency  to  persist.  The  eye  signs 
will  respond  to  an  increase  or  decrease  of  the  rapidity 
of  the  drop,  but  they  are  usually  quite  constant,  fixed  balls, 
contracted  pupils,  absent  lid  reflexes  and  sluggish  corneal 
reflexes  being  the  rule. 

Since  the  anaesthesia  is  under  nice  control,  the  stage  of 
recovery  may  be  begun  earlier.  The  patient  is  usually 
brought  to  the  point  of  vomiting  before  leaving  the  table. 
The  shallow  respirations,  however,  tend  to  retard  the  re- 
turn of  the  reflexes  and  the  return  of  consciousness. 

The  advantages  of  the  open  drop  method  are  as  follows : 

1.  The  simplest  apparatus  is  required. 

2.  Perfect  oxygenation  is  obtained. 

3.  It  is  fool  proof. 

4.  Even  anaesthesia,  easily  controlled  In  suitable  cases. 

5.  The  best  method  for  inducing  anesthesia  when  ether 
alone  is  used. 


ETHER  ANESTHESIA  127 

6.  The  best  method  for  nuiintaining  anaesthesia  in 
young"  children,  when  the  vapor  nietliod  is  not  avaihihle. 

The  disadvantages  of  the  ojjeti  drop  method  are  as 
follows: 

1.  Certain  subjects,  as  vigorous  young  people  and  alco- 
holics, cannot  be  controlled  by  this  method. 

2.  It  is  extremely  wasteful  of  ether. 

3.  The  anesthetist  becomes  literally  soaked  by  the 
ether  forced  into  the  atmosphere  by  the  exhalations. 

4.  The  method  is  frequently  attended  by  acapnia  and 
shock,  through  the  excessive  loss  of  COo.     ( See  page  299.) 

5.  The  jDatient  easily  loses  bodily  heat. 

6.  Induction  is  always  prolonged  and  never  as  pleas- 
ant as  when  N2O  is  used. 

7.  It  is  unsuitable  where  morphine  has  been  used  as  a 
preliminary  medication. 

The  Semi-Open  Drop  Method 

The  semi-open  drop  method  is  nothing  more  than  the 
open  method  so  modified  that  the  communication  wdth  the 
outside  air  is  restricted  and  a  certain  amount  of  rebreath- 
ing  thereby  induced. 

When  this  method  is  employed,  the  drop  method, 
strictly  speaking,  is  not  used  as  consistently  as  in  the  open 
method.  The  necessity  for  concentrated  ether  which  this 
method  usually  implies  calls  for  a  spray  or  pour  method. 
The  open  drop  method  can  easily  be  modified  into  the  semi- 
open  method  by  the  use  of  towels  or  a  rubber  dam. 

By  the  open  drop  method  and  the  semi-open  drop 
method,  one  is  in  a  position  to  handle  every  case  suitable 
for  oral  insufflation.  Any  patient  from  a  baby  to  a  two- 
hundred-pound  alcoholic  may  be  controlled  by  the  use  of 


128 


ANESTHESIA 


these  two  methods.  This  does  not  mecan  that  one  can  thus 
obtain  the  best  results,  but  that  in  an  emergency  we  can 
anaesthetize  any  patient  who  will  respond  to  ether  anses- 
thesia,  if  we  are  given  time  enough  and  sufficient  ether. 

Apparatus. — 1.  The  oDcn  drop  mask  covered  with  at 
least  twelve  layers  of  gauze. 


Fig.  67. — Ether  by  the  semi-open  drop  method.   First  position,   i'lrst  towel  in  place  over  the  eyes. 

2.  Three  small  towels  or  a  piece  of  rubber  dam  6  inches 
by  12  inches  with  a  1-inch  hole  in  the  centre. 

3.  A  bottle  which  will  permit  of  a  spray  or  a  small 
stream  of  ether. 

The  Anaesthesia. — A  folded  towel  is  placed  over  the 
eyes  (Fig.  67).  Anaesthesia  is  induced  precisely  as  with 
the  open  drop  method.  When  the  patient  has  lost  con- 
sciousness, as  will  be  shown  by  his  inability  to  count  intelli- 
gently, the  second  towel  folded  lengthwise  is  placed  over 
the  upper  third  of  the  mask   (Fig.  68),  the  ends  being 


ETHER  ANESTHESIA 


129 


Fig.   68. — Ether  by  the  semi-open  drop  method.    Second  position.    Second  towel  in  place  covering 

upper  third  of  mask. 


Fig.  69. — Ether  by  the  semi-open  drop  method.    Third  position.    Third  towel  in  place  coverinjr 

lower  third  of  mask. 


130 


ANESTHESIA 


tucked  neatly  under  the  occiput.  The  drop  is  now  in- 
creased in  frequency  and  held  just  below  the  point  of 
spasm  of  the  respiration.  The  third  towel  folded  length- 
wise is  now  stretched  over  the  lower  third  of  mask,  one  end 
is  tucked  under  the  head,  the  other  is  left  free  (Fig.  69) . 

We  now  have  two-thirds  of  the  mask  covered  by  towel- 
ing, the  middle  third  is  exposed  and  receives  the  ether 
dropped  upon  the  mask.     With  this  semi-open  method 


Fig.  70. — Ether  by  the  semi-open  drop  method.     Fourth  position.     The  free  end  of  the  third 
towel  is  being  laid  over  the  exposed  third  of  the  mask. 

almost  every  case  can  be  subdued.  When  a  particularly 
obstreperous  case  refuses  to  become  relaxed  the  mask  is 
covered  with  ether  and  the  free  end  of  the  third  towel  is 
thrown  over  the  exposed  portion  of  the  mask.  In  this 
manner  outside  air  is  practically  excluded  and  the  most 
refractory  patient  will  become  anaesthetized  (Fig.  70). 

This  towel  method  will  be  found  very  convenient  and 
effective,  r.s  the  mask  is  thereby  held  in  place,  leaving  both 
hands  of  the  anaesthetist  free. 


ETHER  ANESTHESIA 


131 


A  somewhcat  more  simple  procedure,  but  one  requiring 
an  additional  accessory,  consists  of  covering  the  open  drop 
mask  with  a  sheet  of  rubber  dam.  hnving  a  liole  in  the  cen- 
tre through  which  ether  is  dropped.  This  method  effec- 
tiveh^  restricts  the  admission  of  air,  but  is  somewhat  more 
cumbersome  in  manipulation  (Fig.  71). 


Fig.  71. — Ether  by  the  semi-open  drop  method.     A  piece  of  rubber  dam  with  a  one-inch  hole 
being  used  in  place  of  towels. 

The  advantages  of  the  semi-open  method  over  the  open 
method  in  the  late  stages  of  induction  and  in  maintenance 
are: 

1.  Vigorous  subjects  may  be  anfesthetized, 

2.  Less  waste  of  ether. 

3.  Less  ether  in  the  air  of  the  operating  room. 

4.  Less  likelihood  of  acapnia. 

5.  Less  loss  of  body  heat. 

6.  Induction  is  more  expeditious. 

7.  Because  of  rebreathing,  this  method  may  be  used 
with  more  safety  where  preliminarj^  morphine  and  atropine 
have  been  given. 


132  ANAESTHESIA 

The  disadvantages,  as  compared  with  the  open  method, 
are  as  follows : 

1.  Oxygenation  not  so  good. 

2.  Control  not  so  delicate. 

3.  Not  entireh^  fool  proof. 

4.  Not  so  good  for  early  induction. 

5.  Xot  suitable  for  little  children  who  are  to  he  carried 
in  maintenance  for  some  time. 

The  Closed  Drop  Method 

For  all  patients  with  the  exception  of  very  young  chil- 
dren, seven  years  or  under,  the  closed  drop  method  is  by 
far  the  best  (all  round)  method  of  oral  insufflation.  When 
this  method  is  employed  with  nitrous  oxide  followed  by 
ether,  it  is  not  only  most  efficient  from  the  anaesthetist's 
point  of  view,  but  it  is  also  by  far  the  pleasantest  mode  of 
anaesthesia  for  the  patient. 

This  method  is  separate  and  distinct  from  both  the 
open  and  semi-open  method.  A  suita])le  apparatus  must 
be  employed,  if  one  wishes  to  secure  the  best  results.  The 
apparatus  which  may  be  had  for  the  closed  method  of 
etherization  is  varied.  Our  task  is  to  suggest  features  of 
value  which  should  govern  our  selection. 

1.  It  must  be  possible,  at  the  will  of  tlie  operator,  to 
absolutely  exclude  atmospheric  air ;  otherwise  nitrous  oxide 
cannot  be  satisfactorily  used  for  induction. 

2.  It  should  be  light  in  weight  and  rest  comfortably  on 
the  face. 

3.  It  must  be  possible  to  clean  and  sterilize  the  appara- 
tus. Small  inaccessible  parts,  and  therefore  difficult  to 
clean,  are  to  be  discouraged. 

4.  The  rebreathing  must  be  unobstructed. 


p:ther  anaesthesia  133 

.").  Tliere  sliould  be  some  device  whereby  ether  may  be 
automatically  given  in  small,  frequent  doses,  in  such  a 
manner  as  to  sinmlate  the  drop  method. 

6.  It  should  be  possible  to  easily  and  frequently  change 
the  gauze  or  crinoline,  j^laced  in  the  apparatus  for  the  pur- 
pose of  assisting  in  the  evaporation  of  the  ether. 

7.  It  is  a  great  convenience  to  have  some  arrangement, 
whereby  atmospheric  air  may  be  freely  given  the  patient 
without  removing  the  inhaler  from  the  face. 

8.  It  will  be  found  that  a  transparent  face  piece,  such 
as  is  offered  by  celluloid,  will  be  exceedingly  valuable  in 
watching  the  vomiting,  position  of  the  throat  tube  and  the 
color  of  the  lips. 

When  one  wishes  to  employ  N2O  and  O  for  induction 
and  the  latter  part  of  maintenance  and  recovery,  the  inlet 
for  these  gases  should  be  situated  at  some  point  in  the  ap- 
paratus between  the  bag  and  the  face  piece,  not,  as  is  the 
usual  custom,  by  means  of  a  stopcock  at  the  base  of  the 
bag.  By  the  admission  of  N2O  and  O  in  this  way,  we  may 
have  immediate  results;  we  need  not  wait  for  the  baar  to 
be  emptied.  There  should  also  be  provided  a  valve,  which 
will  allow  the  escape  of  expirations,  but  which  will  prevent 
the  admission  of  air  during  inspiration. 

The  author  has  succeeded  in  embodying  most  of  the 
foregoing  principles  in  a  device,  shown  in  Fig-  72.  Anv 
contrivance  which  exhibits  the  same  principles  will  give 
equally  good  results.  The  above-mentioned  apparatus  is 
a  modification  of  a  standard  face  piece,  the  detailed  con- 
struction of  which  is  unimportant  since  other  face  2^ieces 
might  be  substituted  with  equally  good  results. 

The  following  features  of  this  apparatus  are  worthy 
of  notice : 


134 


ANESTHESIA 


1 .  A  device  for  giving  ether  by  the  closed  drop  method. 
This  consists  of  an  ordinary  oil  cup  with  a  sight  feed. 

The  cup  is  filled  with  ether  as  required,  and  the  drop  is 
regulated  by  a  screw  at  the  top.  This  cup  forms  a  part  of  a 
section  which  may  be  easily  slipped  on  and  off  the  face 
piece  section. 

2.  A  tube  for  the  admission  of  the  gases  N2O  and  O, 
located  between  the  bag  and  the  face  piece.  This  is  also 
part  of  the  above-mentioned  section. 


Fig.  72.— The  author's  apparatus  for  the  administration  of  ether  by  the  Closed  Drop  Method 
and  for  Gas  Oxygen  Ether  Ansesthesia. 

3.  An  expiratory  valve  for  use  when  N2O  and  O  are 
used. 

4.  The  entire  apparatus  weighs  only  two-thirds  as 
much  as  the  well-known  Bennett. 

5.  The  face  piece  is  comfortable  and  transparent. 

6.  Atmospheric  air  may  be  readily  and  freely  ad- 
mitted through  the  air  valve  without  removing  the  face 
piece. 

7.  The  use  of  a  roll  of  fine  wire  gauze,  100  to  the  inch, 
for  an  evaporating  surface  (Fig.  73). 

The  last  feature  named  is  of  the  utmost  importance. 


ETHER  ANAESTHESIA  135 

as  will  be  seen  in  the  following  consideration:  The  wire 
gauze  in  strips  2  inches  by  15  inches  is  rolled  up  like  a 
jelly  roll.  This  roll  is  placed  in  the  ether  cup  section  so 
that  the  ether,  which  drops  into  the  apparatus,  will  become 
entangled  in  its  meshes.  There  is  practically  no  obstruc- 
tion to  the  respiration,  which  passes  freely  through  this 
wire  tube.  The  evaporating  surface  is  large,  and  the 
material  does  not  collapse  when  wet  with  ether. 


Fig.  73. — Wire  gauze  roll;  size,  100  to  the  inch, 

ADMiNiSTRATiotN^. — ^Whcu  the  closed  drop  method  is 
employed. 

Induction. — With  the  air  vent  open,  the  wire  gauze  in 
place,  and  the  ether  in  the  cup,  the  bag  is  filled  with  gas. 
The  face  piece  is  then  adjusted  and  the  patient  is  permitted 
to  breathe  the  air.  After  a  few  moments,  the  air  vent  is  closed 
and  the  patient  breathes  nitrous  oxide  to  and  fro.  At  the 
end  of  about  forty  seconds,  or  when  the  respirations  become 
involuntary,  as  is  shown  by  their  increased  depth  and  rap- 
idity, ether  is  very  cautiously  added  drop  by  drop.  The 
frequency  of  the  drop  is  increased  as  rapidly  as  possible 
without  causing  spasm  of  the  respiration.  The  rubber  tube 
which  admitted  the  N2O  mav  now  be  detached.     The  air 


136  ANAESTHESIA 

which  may  enter  through  this  tube  will  not  be  found  ob- 
jectionable. By  opening  the  air  vent  during  inspiration 
and  closing  it  during  expiration,  we  may  oxygenate  the 
patient  and  dilute  the  percentage  of  the  ether  in  the  bag. 
Stertor  usually  appears  when  we  have  vaporized  about 
half  an  ounce  of  ether. 

Consciousness  is  lost  easily  and  pleasantly.  The  period 
of  excitement  is  reduced  to  a  minimum.  Spasm  of  the  res- 
piration sometimes  occurs,  but  nmscular  movements  are 
rare.  The  respiration,  unobstructed  by  tightly  packed 
gauze,  is  usually  full  and  deep ;  the  color  responds  quickly 
to  oxygenation  by  the  atmospheric  air.  When  it  does  not 
so  respond,  oxygen  may  rapidly  be  admitted  through  the 
tube  designed  for  this  purpose.  The  color  of  the  lips  may 
readily  be  seen  through  the  transparent  face  piece. 

The  lid  reflex  disappears  and  the  masseters  become  re- 
laxed. The  eyeballs  soon  become  fixed  and  the  pupils 
somewhat  contracted.  The  light  reflex,  however,  remains 
active  and  the  corneal  reflex  sluggish.  In  this  condition 
the  patient  enters  the  stage  of  maintenance. 

Before  describing  the  stage  of  maintenance,  we  may 
say  that  the  induction  of  anaesthesia  by  the  closed  drop 
method  will  give  as  good  results,  and  occasionally  better 
results,  than  the  pour  methods  usually  employed  with  other 
apparatus.  It  is  in  the  stage  of  maintenance,  however, 
that  this  method  becomes  most  useful. 

Maintenance. — If  the  breathing  is  not  perfectly  satis- 
factory, we  will  do  well  to  introduce  a  throat  tube.  (Fig. 
14.)  This  will  guard  against  oral  obstruction  during  the 
subsequent  ana^sthetization.  The  operative  procedure  hav- 
ing been  commenced  without  disturbing  the  patient,  we  may 
set  the  drop  at  a  rate  which  seems  most  fit,  in  view  of  the 


ETHER  ANESTHESIA  137 

character  of  the  induction.  If  the  latter  has  been  stormy 
and  dehiyed,  we  will  be  obliged  to  exercise  more  control  over 
the  early  stages  of  maintenance.  At  frequent  intervals, 
depending  upon  the  patient's  color  and  the  depth  of  the 
respiration,  we  fill  the  bag  partially  or  completely  with 
fresh  air.  If  the  inlet  tube  for  the  gas  be  oj^en  all  the  while, 
permitting  the  gradual  escape  .of  the  contents  of  the  bag, 
it  will  be  found  unnecessary  to  completely  empty  the  bag, 
except  when  the  respirations  become  unusually  deep  or 
the  patient  perspires  freely.  The  simple  adding  of  atmos- 
pheric air  through  the  air  valve  will  "be  all  that  is  required 
to  keep  an  even  and  tranquil  anaesthesia.  If  the  patient 
requires  much  ether,  it  is  advisable  to  add  air  more  fre- 
quently in  addition  to  increasing  the  speed  of  the  drop. 
This  closed  drop  method  approaches  the  ideal  which  is 
offered  by  the  percentage  method.  With  a  free  respiration, 
as  is  provided  by  the  throat  tube,  a  non-obstructing  but 
efficient  evaporating  surface  and  a  visible  automatic  drop, 
we  have  the  patient  under  a  delicate  and  even  control.  As 
one  becomes  familiar  with  the  signs  of  anaesthesia,  he  can 
carry  a  low  level,  changing  rapidly  to  a  higher,  as  required 
by  special  manipulations.  From  a  rather  extensive  and 
recent  personal  experience  with  this  method,  in  experienced 
as  well  as  in  inexperienced  hands,  the  author  is  satisfied  that 
it  is  the  best  method  where  a  variable  but  absolutely  con- 
trollable level  of  maintenance  is  desired. 

Recovery. — We  know  of  no  method  of  ana?sthetization 
which  will  permit  the  anaesthetist  to  begin  the  stage  of  re- 
covery as  soon  as  will  the  closed  drop  method.  The  anaes- 
thesia being  under  perfect  control,  one  may,  for  example, 
in  an  abdominal  section,  stop  the  drop  as  soon  as  the  peri- 
toneum is  closed,     ^^^^ile  the  patient  rebreathes  his  own 


138  AN.ESTHESL\ 

expirations  to  and  fro  in  the  bag,  he  tends  to  lower  the 
tension  or  percentage  of  ether  present  in  his  circulation. 
We  may  easily  further  decrease  the  strength  of  this  ether 
by  reducing  the  rebreathing  and  adding  atmospheric  air. 
Confidence  born  of  control  Avill  allow  one  to  attempt  light- 
ness, w^hich,  under  other  circumstances,  would  court  failure. 
If  the  anaesthetist  is  watchful,  he  can  always  recover  the 
reflexes  before  the  patient  leaves  the  table. 

As  the  rebreathing  induces  respirations  of  large  tidal 
volume,  the  ether  in  the  circulation  is  rapidly  thrown  off 
and  the  second  period  of  recovery  or  the  return  of  con- 
sciousness is  soon  completed. 

The  medical  profession  and  the  general  public  owe  a 
debt  of  gratitude  to  Dr.  Thomas  Bennett  of  New  York 
City  for  introducing  gas  ether  anaesthesia  in  this  country. 
We  believe  that  the  success  of  his  apparatus  lay  in  the 
fact  that  it  was  one  of  the  earliest  in  which  the  gas  ether 
sequence  was  used,  and  furthermore  that  the  method  em- 
ployed was  a  closed  one.  The  device  became  known  by 
its  constant  use  by  Dr.  Bennett  and  later  gave  its  author 
wide  publicity.  As  this  device  is  found  in  a  large  number 
of  hospitals,  it  deserves  more  than  a  passing  glance.  While 
cumbersome  and  costlj;,  it  will  yet  give  splendid  results  in 
experienced  hands.  (Figs.  74,  75.)  It  is  arranged  for  a 
nitrous  oxide  ether  sequence.  The  ether  is  given  by  pour- 
ing it  upon  the  gauze,  packed  in  the  ether  chamber  through 
small  holes  in  the  sides  of  the  same.  Before  starting,  the 
ether  chamber  should  be  closely  packed  with  gauze  ( it  must 
be  remembered  that  the  patient  does  not  breathe  through 
this  gauze,  but  around  it)  in  the  space  between  the  cage 
and  the  air-tight  wall  of  the  ether  chamber.  Tlie  gauze  in 
the  ether  chamber  is  then  well  moistened  with  ether,  about 


ETHER  ANAESTHESIA 


139 


lialf  an  ounce  being  poured  in.  The  indicator  is  turned  to 
"  air."  The  gas  bag  is  filled  and  the  face  piece  is  applied. 
The  patient  is  made  to  rebreathe  X2O.  When  the  respira- 
tions become  deep  and  more  rapid  than  normal,  the  ether 
is  cautiously  turned  on.  If  there  is  no  respiratory  spasm, 
it  is  "•raduallv  increased.  When  full  ether  is  reached,  the 
gas  bag  is  replaced  by  the  rebreathing  bag.  A  small 
amount  of  ether  is  poured  into  the  ether  chamber,  through 
each  of  the  three  holes.    Relaxation  comes  on  quickly  and 


Figs.  74. — Bennett  apparatus,  with  gas  attachment 
and  bag  for  induction. 


Fig.  75. — Bennett  apparatus  with  ether 
rebreathing  bag  for  maintenance. 


the  stage  of  maintenance  is  soon  reached.  When  properly 
managed,  the  stage  of  induction  is  all  that  can  be  desired. 

During  the  stage  of  maintenance,  however,  we  are 
likely  to  feel  that  improper  provision  has  been  made  for: 

(a)  The  changing  of  the  gauze,  which  has  become 
water  soaked  by  the  condensed  respiratory  moisture;  ih) 
the  giving  of  small,  constant  doses  of  ether;  (c)  unob- 
structed rebreathing. 

Furthermore,    we    cannot    see    the    patient's    mouth 


140  ANESTHESIA 

through  the  opaque,  metal  mask  and,  after  an  hour  or 
more,  the  weight  of  the  apparatus  hecomes  trouhlesome. 

Unless  one  is  very  expert,  the  patient  will  not  be  under 
proper  control.  The  wet  gauze  will  not  hold  the  ether 
poured  upon  it,  allowing  the  latter  to  run  down  into  the 
face  piece.  With  care  and  good  judgment  these  disad- 
vantages are  not  so  marked.  They  will  be  found  especially 
noticeable,  however,  with  the  beginner,  who  has  not  de- 
veloped the  skill  necessary  for  their  proper  avoidance. 

The  stage  of  recovery  cannot  be  started  as  early  as  one 
would  wi^h  for  the  reason  that  the  control  is  not  sufficiently 
delicate.  The  return  of  consciousness  is  delayed,  since  it 
has  been  necessary  to  carry  a  high  level  of  maintenance; 
a  low  level  being  dangerous,  as  spasm  supervenes  where 
ether  is  added  too  freely. 

We  have  taken  the  liberty  of  selecting  the  Bennett 
apparatus  as  a  popular  and  widely  used  exemplification  of 
a  type,  which  does  not  offer  the  most  satisfactory  means 
of  inducing  and  maintaining  anesthesia,  especially  from 
the  point  of  view  of  the  beginner.  Long  usage,  mixed  w^ith 
interest  and  intelligence,  as  has  been  before  mentioned, 
often  overcomes  these  shortcomings. 

The  device  which  the  author  employs  is  also  one  show- 
ing forth  a  type,  the  detailed  construction  of  which  is  in- 
cidental and  which  may  easily  be  improved  upon. 

The  Disadvantages  of  the  Closed  Drop  Method  as 
Compared  With  the  Open  and  Semi-Open  Drop 
Method 

1.  The  apparatus  is  more  cumbersome  and  expensive. 

2.  It  cannot  be  used  when  the  tidal  volume  is  unusu- 
ally small,  as  in  babies  and  very  young  children. 

3.  It  is  not  fool-proof. 


ETHER  ANAESTHESIA  141 

The  Advantages  of  the  Closed  Drop  Method  as  Com- 
pared Avnii  THE  Open  and  Semi-Open  Drop  Method 

1.  It  may  be  used  with  more  efficiency  in  a  larger  range 
of  cases. 

2.  Tlie  ability  to  use  X^O  gives  a  speedier  and  pleas- 
anter  induction. 

3.  It  is  most  economical  in  the  use  of  ether. 

4.  The  body  heat  is  preserved. 

5.  The  rebreathing  prevents  acapnia. 

C.  Preliminary  morphine  medication  may  be  used  with 
greater  safety. 

7.  The  control  of  the  patient  is  more  delicate  and 
effective. 

8.  The  stage  of  recovery  may  be  begun  earlier. 

9.  During  the  stage  of  induction  and  maintenance, 
oxygen  may  be  given  in  the  most  effective  manner,  namely, 
mixed  with  CO^. 

10.  During  the  stage  of  recovery  N^-O  and  O  may 
be  used  and  much  of  the  ether  may  thus  be  thrown  off. 

11.  The  operating  room  is  almost  free  from  the  odor  of 
ether. 

12.  The  anajsthetist  may  give  ether  all  day  and  at  the 
close  have  absorbed  little  or  no  ether  himself. 

Observations  on  the  Use  of  the  Open  and  Semi-Open 
Drop  Methods  in  Large  Clinics,  a^ith  Special 
Reference  to  the  Means  Employed  to  Overcome 
THE  Objectionable  Features  of  These  Methods 

In  observing  the  anaesthesia  at  various  clinics,  we  are 
forced  to  the  conclusion  that  differences  of  opinion  exist 
in  regard  to  the  definition  of  "  A  good  anaesthesia. "  We 
are  under  the  impression  that  a  good  ana?sthesia  im^^lies: 
A  rapid  and  pleasant  loss  of  consciousness,  a  short  period 


142  ANAESTHESIA 

of  excitement,  a  relaxation,  which  comes  on  quickly  and 
which  is  well  under  way  before  the  operation  is  commenced, 
a  stage  of  maintenance  under  the  comj^lete  and  ready  con- 
trol of  the  amesthetist  and  a  knowledge,  on  the  part  of  the 
anaesthetist,  of  the  exact  depth  of  the  anesthesia  at  any 
given  time.  To  our  surprise,  we  often  find  a  satisfactory 
anaesthesia  summarized  in :  A  delayed  and  distressing  loss  of 
consciousness ;  a  period  of  excitement  often  prolonged  and 
followed  by  rigidity  extending  well  into  the  course  of  the 
operation,  which  is  habitually  begun  so  early  that  there  is 
almost  invariably  a  reflex  rigidity  as  a  consequence;  an 
uneven  stage  of  maintenance,  not  under  good  control  and 
leading  rather  than  being  led  by  the  anaesthetist.  The 
keynote  of  a  good  anasthesia  appearing  to  be,  to  give  as 
little  ether  as  possible  regardless  of  the  convenience  of 
the  surgeon,  who  must  adapt  himself  to  this  essential. 

There  is  no  doubt  that  such  a  method  of  anasthesia  is 
seldom  exposed  to  the  danger  of  overdosage,  or  of  vagus 
inhibition,  because  fortunately  the  anasthetic  is  not  chloro- 
form but  ether.  Ether  may  be  given  in  this  fashion  with 
comparative  safety  by  a  lay  person,  who  need  pay  little 
attention  to  the  signs  of  anasthesia,  the  essential  indication 
being  to  increase  the  amount  of  ether  administered  when 
the  patient  coughs  or  moves,  and  to  reduce  the  amount  or 
stop  the  ether  if  the  patient  is  quiet. 

The  delay  in  the  induction  of  anasthesia  by  this  method 
of  open  and  semi-open  drop  ether  is  overshadowed  by  one 
or  all  of  five  reasons: 

1.  The  fact  that  operations  are  going  on  in  more  than 
one  operating  room  at  the  same  time,  and  visitors  are  not 
obliged  to  wait  for  the  next  patient  but  may  be  otherwise 
entertained. 


ETHER  ANESTHESIA  143 

2.  The  patient  is  anfesthetized  on  the  operating  table 
in  the  operating  room,  and  the  dehiy  incidental  to  trans- 
portation after  anaesthesia  is  induced  is  ohviated. 

3.  If  tlie  operative  position  is  a  difficult  one  to  obtain, 
i.e.^  for  kidney  work,  the  patient  is  placed  in  tliis  position 
before  the  anaesthesia  is  induced. 

4.  The  preparation  of  the  field  of  o^^eration  takes  place 
as  soon  as  the  patient  is  on  the  table,  usually  before  con- 
sciousness is  lost. 

5.  Lastly,  and  of  great  practical  importance,  the  pa- 
tient is  thoroughly  restrained  by  strapping.  This  obviates 
the  danger  of  his  lifting  his  hand  in  a  subconscious  effort 
to  protect  himself  when  the  first  incision  is  made,  as  would 
certainly  occur  in  many  of  these  cases  where  the  operation 
is  begun  during  the  early  periods  of  induction. 

This  control  makes  possible  a  method  which  otherwise 
could  not  be  tolerated. 

The  rigiditi/  incidental  to  incomplete  aniesthesia  is 
largely  overcome  by  the  employment  of  large  incisions  and 
the  use  of  self-retaining  retractors. 

In  discussing  this  method  of  anaesthesia,  we  try  to  sepa- 
rate it  from  the  fame  which  it  sometimes  borrows  from 
its  environment  and  to  consider  it  per  se,  as  it  would  actu- 
ally appear  if  shorn  of  its  surgical  support  and  trans- 
planted to  a  locality  where  it  would  be  obliged  to  stand 
upon  its  own  merits ;  for  this  is  the  condition  obtaining  with 
those  who  adopt  this  method.  Possibly  under  some  con- 
ditions no  better  method  can  be  found. 

The  Administration. — Patients  who  are  able  to  walk 
are  sometimes  assembled  in  a  small  waiting  room  a  short 
distance  from  the  operating  rooms.  When  the  operating- 
room  is  dressed,  they  walk  in,  disrobe  and  lie  upon  the 


144  ANESTHESIA 

table.  A  strap  is  then  thrown  over  the  knees  and  bands 
of  webbing,  sometimes  two,  sometimes  four,  hold  the  arms 
to  side. 

The  nurse  speaks  a  few  words  to  the  patient  and,  after 
covering  the  eyes  with  gauze,  begins  the  administration  of 
ether  by  the  drop  method.  The  mask,  at  first  some  dis- 
tance from  the  face,  is  gradually  lowered  as  anesthesia 
progresses.  Consciousness  persists  for  from  three  to  four 
minutes.  Since  the  respirations  are  shallow,  the  induction 
is  delayed  so  that  at  the  end  of  ten  minutes  marked  rigidity 
is  often  still  present  and  reflexes  to  pain  persist.  The  open 
drop  mask  is  sometimes  converted  into  a  semi-open  mask 
by  winding  a  strip  of  gauze  about  it,  something  after  the 
fashion  of  a  bandanna  handkerchief.  The  preparation  of 
the  field  of  operation  begins  before  consciousness  is  lost  and 
is  usually  concluded  before  the  induction  is  well  under  way. 
When  the  jjreparation  is  complete,  the  incision  is  fre- 
quently made,  often  with  little  respect  for  the  signs  of 
anesthesia.  If  the  patient  resists,  the  operator  is  con- 
strained to  wait.  If  the  resistance  is  slight  it  is  usually 
overlooked.  Since  the  patient  is  well  restrained  the  danger 
of  his  hand  finding  its  way  to  the  wound  is  slight.  The 
pain  of  the  first  incision  usually  stimulates  the  respiration 
so  that  a  certain  amount  of  ether  is  eventually  absorbed. 

During  the  stage  of  maintenance,  the  chief  symptoms 
observed  are  presence  or  absence  of  straining  or  movement, 
coughing  or  retching.  Little  effort  is  made  to  anticipate 
these  signs  and  their  occasional  appearance  is  usually 
overlooked. 

The  incomplete  relaxation  which  obtains,  prevents  ob- 
struction of  the  airway  by  the  falling  back  of  the  tongue, 


ETHER  ANAESTHESIA  145 

but  on  the  other  hand  permits  masseteric  spasm  by  reflex 
irritation. 

The  stage  of  recovery  is  what  might  be  expected  from 
the  use  of  this  method,  the  advantages  and  (hsadvantages 
of  which  have  been  taken  up  in  a  preceding  section,  page 
127. 

It  may  not  be  unfair  to  assume  then  that  the  open  or 
semi-open  drop  method  is  the  routine  method  of  choice  in 
some  chnics: 

1.  Because  it  is  so  safe  as  to  permit  its  administration 
by  lay  people. 

2.  Because  it  is  the  belief  of  the  authorities  that  the 
use  of  small  amounts  of  ether  is  more  important  than  the 
obtaining  of  complete  relaxation. 

3.  Because  such  a  method  involves  apparatus  of  the 
simplest  possible  ty23e. 

4.  Because  provision  may  be  made  for  the  delaj'ed  in- 
duction incidental  to  drop  ether  by  placing  the  patient  in 
the  operative  position  on  the  operating  table,  in  which  posi- 
tion he  is  restrained  and  the  anaesthetic  started.  The  field 
of  operation  being  prej^ared  at  once  and  little  heed  being 
paid  by  the  audience,  who  are  entertained  in  neighboring 
rooms. 

5.  Because  provision  may  be  made  for  imperfect 
relaxation  by  employing  large  incisions  and  self-retaining 
retractors. 

The  Vapor  Method  of  Oral  Insufflatiox 

In  the  vapor  method  of  oral  insufflation,  we  offer  ether 
to  the  patient  in  vapor  form.  The  respiration  has  nothing 
to  do  with  the  production  of  this  vapor,  which  is  brought 
about  by  mechanical  means. 

It  is  not  our  object  to  catalogue  the  various  apparatus 

10 


146  ANESTHESIA 

at  our  disposal  but  to  reduce  the  method  to  its  simj)lest 
terms.    We  will  attempt  to  describe  the  most  simple  form 
of  vajDor  ana?sthesia.  a  method  which  has  given  continued 
satisfaction  in  the  hands  of  many  operators. 
Apparatus. — 

1.  Cautery  bellows  or  tank  of  oxygen. 

2.  A  suitable  bottle  for  vaporizing  the  ether. 

3.  A  suitable  mask,  through  which  the  patient  receives 
the  vapor  delivered. 

1.  The  bellows  and  the  oxygen  tank  need  no  explana- 
tion. 

2.  The  wash  bottle  attached  to  the  operating  room  oxy- 
gen tank  will  make  a  perfectly  satisfactory  vaporizing  bot- 
tle. This  is  usually  an  eight-ounce  bottle  with  a  large  neck, 
into  which  fits  a  rubber  cork  perforated  with  two  holes. 
Through  one  of  these  holes  passes  a  tube  long  enough  to 
pass  below  the  surface  of  the  ether.  Through  the  other  a 
small  tube,  which  reaches  just  below  the  cork.  The  cau- 
tery bellows  or  tubing  from  the  oxygen  tank  is  attached 
to  the  long  tube,  so  that  when  air  or  oxygen  is  introduced, 
it  will  bubble  through  the  ether.  The  short  tube,  for  the 
exit  of  the  vapor,  is  connected  with  tubing  which  leads  to 
the  face  piece  (Fig.  76). 

B.  The  ordinary  semi-open  drop  mask  may  be  em- 
ployed by  passing  the  tube,  which  delivers  the  vapor,  be- 
neath this.  AAHien  purchasing  a  drop  mask,  however,  the 
best  plan  is  to  buy  one  designed  for  use  with  vapor,  as 
shown  in  Figs.  65  and  77.  This  mask  will  therefore  serve 
the  double  purpose  of  drop  and  vapor  mask. 

The  vapor  method  of  oral  insuffiation  is  especially 
adaf)ted  to  babies  and  very  young  children.  We  know  of 
no  method  which  is  subject  to  as  delicate  a  control.     The 


ETHER  ANAESTHESIA 


147 


FiQ.  76. — Apparatus  for  the  vapor  method  of  oral  insufflation  and  for  intrapharjmgeal 
insufflation  where  concentrated  vapor  of  small  volume  is  employed.  Showing  oxygen  tank, 
cautery  bellows,  wash  bottle  in  which  ether  is  placed,  Lumbard  vapor  mask,  throat  tube  and 
nasal  tubes. 

tidal  volume  of  a  baby's  respiration  is  often  so  small  that 
it  will  not  properly  vaporize  ether  dropped  upon  the  mask. 
No  argument  is  necessary  to  emphasize  the  value  of  the 

A  device  for  heating  the 


vapor  method  in  these  cases. 


148  ANESTHESIA 

ether  container  is  unnecessary,  as  the  evaporation  is  com- 
paratively slow.  In  those  unusual  cases  where  heat  is 
desired,  the  most  simple  method  of  applying  this  is  to  set 
the  ether  bottle  in  a  dish  of  hot  water;  any  dish  will  do. 
We  are  never  without  hot  water  where  an  operation  is  to 
be  performed,  while  electrical  conveniences  are  frequently 
absent.  The  addition  of  heat  increases  the  concentration 
of  the  ether  vapor  from  60  per  cent,  or  less  to  almost  100 
per  cent.     See  page  70. 

It  will  be  found  that  the  use  of  oxygen,  instead  of 
atmospheric  air  by  the  bellows,  is  not  only  more  efficient 


Fig.   77. — Vapor  mask. 

because  it  provides  thorough  oxygenation,  but,  being  auto- 
matic, it  is  much  easier  of  administration  and  can  readily 
be  controlled.  The  expense  is  of  small  consequence,  as  the 
ether  necessary  to  control  an  adult  in  this  manner  will  be 
vaporized  by  less  than  twenty  gallons  of  O  per  hour,  repre- 
senting an  expense  of  less  than  one  dollar.  An  infant  re- 
quires much  less. 

The  Administration. — The  administration  is  exceed- 
ingly simple,  our  chief  care  being  to  give  the  vapor  gradu- 
ally and  to  watch  carefully  for  signs  of  deep  anaesthesia, 
as  exhibited  by  a  rapid  respiration  and  a  fixed,  dilated 
pupil.     In  very  young  children,  our  chief  care  should  be 


ETHER  ANESTHESIA  149 

to  keep  the  small  patient  quiet  with  as  little  anaesthesia  as 
possible. 

For  any  type  of  operation  in  babies  and  small  children, 
where  the  oral  method  of  insufflation  will  suffice,  we  believe 
that  this  vapor  method  will  give  the  best  results. 

II.  INTRAPHARYNGEAL  INSUFFLATION 

In  intrapharyngeal  insuffiation,  instead  of  presenting 
ether  to  the  paljient  in  the  external  atmosphere,  which  he 
breathes,  we  go  a  step  further  and  place  the  ether  vapor 
in  the  posterior  pharynx.  It  is  unnecessary  to  state  that 
the  ether  must  be  previously  vaporized.  It  cannot  be 
given,  as  with  oral  insufflation,  in  both  the  liquid  and  the 
vapor  form. 

There  are  two  distinct  methods  of  giving  ether  by  the 
intrapharyngeal  insufflation : 

{a)  In  the  first,  we  supply  to  the  patient  a  mixture  of 
ether  and  air  of  sufficient  volume  to  meet  all  his  respiratory 
needs.  This  volume  ranges  from  twelve  to  eighteen  liters 
a  minute.  We  not  only  do  not  depend  upon  the  addition 
of  atmospheric  air,  but  we  exclude  it  by  giving  the  vapor 
under  a  pressure  ranging  from  20  to  40  mm.  of  mercury. 

(b)  In  the  second  case,  we  give  the  patient  a  small 
volume  of  very  concentrated  ether  and  depend  upon  the 
mixture  of  atmospheric  air  to  both  dilute  this  and  supply 
the  total  volume  necessary. 

The  jirst  method  is  of  course  the  ideal,  since  it  enables 
us  to  completely  control  the  percentage  of  the  ether  in- 
haled. Knowing  the  limits  of  depth  and  lightness  in  terms 
of  vapor  tension  to  be  about  180  mm.  to  .50  mm.  (see  page 
64  et  seq. )  our  control  of  the  patient  well-nigh  approaches 
perfection. 


150 


ANAESTHESIA 


This  type  of  intrapharyngeal  insufflation  is  best  exem- 
plified by  the  apparatus  known  as  the  anaesthetometer, 

78). 


designed  by  Dr.  K.  Connell 


Fig. 


Fig.   78. — ^Ansesthetometer.     Designed  by  Dr.  K.  Connell. 

Apparatus  for  Ixtkapharyngeai,  Insufflation. — 
There  are  three  divisions: 

1.  The  air  supply. 

2.  The  mixing  chamber. 

3.  The  section  for  delivery  to  the  patient. 

1.  The  air  supply  may  be  procured  by  foot  power. 


ETHER  ANESTHESIA  151 

steam  or  electricity.    There  may  or  may  not  be  a  reservoir 
for  the  air. before  entrance  to  the  mixing  chamber 

Foot  power  will  be  found  satisfactory  where  the  bellows, 
shown  in  Fig.  79,  is  employed.  Steam  power  is  the  type 
used  at  Roosevelt  Hospital,  Xew  York  City.  The  plant 
is  somewhat  costly  and  cumbersome  for  any  but  a  large 


Fig.  79. — Foot  bellows. 


institution  (Figs.  80  and  81).    Electrical  power  (Fig.  82) 
is  quite  satisfactory. 

2.  The  mixing  chamber.    The  Ana?sthetometer. 

3.  The  section  to  the  patient  consists  of  a  rubber  tubing 
to  which  is  attached  a  so-called  nasal  tube.  (Figs.  83  and 
84.) 

The  nasal  tube  is  constructed  of  nickel-plated  brass  of 
a  shape  corresponding  to  the  patient's  face.  It  ends  in  two 
nipple-like  projections  which  are  bent  so  as  to  enter  the 
nostrils  and  prevent  angulation  of  the  catheters  which  are 
attached  thereto.  The  catheters  usually  employed  are  Xo. 
18  French,  velvet-eyed.  Special  catheters  have  been  de- 
signed having  open  ends  resembling  a  small  rectal  tube  in 


Fig.  80. — Steam  pump  for  air  supply  at  Roosevelt  Hospital.   (Courte.s\-  Dr.  K.  Connell.j 


Fig.  81.- 


-Large  reservoir  tank  and  wash  tank  into  which  air  from  steam  pump  is  delivered 
before  being  piped  to  the  operating  rooms.    (Courtesy  Dr.  K.  Connell.) 


ETHER  ANAESTHESIA 


153 


construction.  Tliese,  while  efficient,  are  not  entirely  neces- 
sary. The  length  of  the  catheter  to  be  used  is  equal  to  the 
distance  between  the  a\se  of  the  nose  and  the  auditory 
meatus.     This  distance  carries  the  tube  well  into  the  pos- 


FiG.  82.— Electrical  unit  (Connell). 


terior  pharynx.  If  the  tube  is  made  too  long  it  will  enter 
the  oesophagus  and  dilate  the  stomach.  It  nnist  be  prop- 
erly lubricated  or  a  nose  bleed  will  result. 

The    Administration. — The    induction    is    usually 


154 


ANAESTHESIA 


brought  about  by  the  employment  of  a  semi-open  or  closed 
drop  method.  When  the  patient  has  entered  the  stage  of 
maintenance,  the  vapor  apparatus  is  started,  the  indicator 
being  placed  at  60  or  70  mm.  The  catheters,  well  mois- 
tened with  the  patient's  saliva,  are  slipped  gently  into  each 
of  the  nostrils.     If  one  is  occluded,  both  catheters  may  be 


Fig.   as.  —  Nasal  tubes 


Fig.   84.^Nasal  tube  in  place. 


placed  in  one  nostril.  In  accomplishing  this,  one  should  ele- 
vate the  tip  of  the  nose  and  keep  the  catheters  close  to  the 
floor  of  the  nares.  The  operation  is  completed  by  placing  an 
adhesive  strip  over  the  nasal  tube.  Fig.  85  shows  insertion 
of  the  catheters. 

Fig.  86  shows  catheters  in  position. 

The  anesthesia  may  now  be  continued  with  the  head 


Fig.  85. — Intrapliaryngeal  anaesthesia,  showing  the  insertion  of  the  nasal  tubes.  The 
catheters  are  moistened  with  the  patient's  saliva.  The  nose  is  tilted  backward  and  the  tubes 
are  passed  along  the  floor  of  the  nose  downward  and  backward. 


Fig.  86. — Intrapharyngeal   anaesthesia.     Nasal   tubes  in  place  and  strapped  to  the  patient's 
forehead    by    adhesive    plaster. 


156  ANiESTHESIA 

covered  by  towels  and  the  anesthetist  at  some  distance 
from  the  patient.  One  gradually  reduces  the  percentages 
beginning  at  the  end  of  half  an  hour,  until  40  or  .50  mm.  is 
reached,  at  which  point  the  patient  may  be  carried  for 
hours. 

As  has  been  before  stated  this  type  of  ana?sthesia  is  con- 
stant and  does  not  attempt  to  vary  its  level  according  to 
the  manipulations  of  the  surgeon. 

The  anaesthetist  must  be  continually  alive  to  the  patient 
and  the  apparatus,  however,  for  trouble  may  arise  in  either 
or  both.  This  trouble  will  be  more  difficult  to  detect  and 
must  be  met  more  promptly  than  where  a  more  simple 
method  is  emj^loyed. 

The  second  method,  in  which  a  small  volume  of  very 
concentrated  ether  is  given,  depending  upon  the  patient  to 
dilute  this  with  atmospheric  air,  is  offered  for  that  very 
large  class  of  patients,  particularly  in  private  work,  where 
the  percentage  method  is  not  available.  This  method  at  its 
best  but  approaches  the  ideal  offered  by  the  former.  It  will 
be  found  very  serviceable  and  efficient,  however,  if  prop- 
erly managed  and  will  enable  one  to  meet  those  manj^  re- 
quirements for  nasal  anesthesia  encountered  outside  the 
hospital. 

The  Apparatus. — The  apparatus  is  identical  with  that 
suggested  for  the  vapor  method  of  oral  insufflation  with  the 
difference  that  we  substitute  the  nasal  tubes  for  the  vapor 
mask.    A  throat  tube  is  also  necessary. 

When  intraj)haryngeai  insufflation  is  administered  in 
this  fashion,  it  is  very  important  to  use  the  throat  tube. 
This  will  insure  the  proper  tidal  volume  and  sufficient  air 
to  dilute  the  concentrated  ether  delivered  into  the  pharynx. 
In  order  to  keejJ  the  patient  sufficiently  anesthetized,  how- 


ETHER  ANESTHESIA  157 

ever,  one  will  find  it  necessary  to  induce  a  certain  amount  of 
rebreathing.  This  is  most  easily  accomplished  by  the 
towels  which  are  placed  over  the  patient's  head  for  the 
asepsis  of  the  field  of  operation.  These  towels  may,  with 
advantage,  be  placed  in  position  at  the  early  convenience 
of  the  operator. 

When  in  position  they  should  not  lie  directly  upon  the 
rebreathing  tube  but  at  some  distance  from  it. 

The  Admixistratiox. — Anaesthesia  is  induced  by  the 
open,  semi-open  or  closed  drop  method.  When  the  stage 
of  maintenance  has  been  entered  upon,  the  catheters  are 
slip2)ed  gently  into  place.  Ether  vaj^or  is  then  slowly  bub- 
bled through  these  (preferably  by  oxygen)  into  the  poste- 
rior pharynx.  The  throat  tube  should  now  be  introduced. 
If  the  ether  vapor  causes  cough  or  sj^asm,  stop  the  vapor 
but  do  not  remove  the  tubes.  Give  ether  orally  by  the  drop 
method.  Tolerance  will  soon  be  established  for  the  vapor, 
and  when  spasm  no  longer  occurs  the  vapor  will  be  freely 
admitted  and  the  drop  method  discontinued.  The  mask, 
however,  is  held  over  the  mouth  until  complete  control  of 
the  patient  is  established.  The  freedom  of  both  hands 
w^hich  the  oxygen  method  affords  at  this  stage  w^ill  be  found 
a  great  convenience.  When  the  sterile  towels  are  placed 
over  all,  the  anaesthetist  should  make  sure  that  they  do  not 
block  the  pharyngeal  tube.  In  this  type  of  maintenance 
we  must  watch  the  patient  somewhat  more  closely  than  in 
the  percentage  method.  For  our  maintenance  is  here  of 
the  variable  type  and  depends  upon  the  signs  imme- 
diately expressed  by  the  patient  for  an  elevation  or  de- 
pression of  the  level  which  is  carried.  It  is  always  safer 
to  carry  the  patient  too  low  than  too  high,  for  many 
of    the    signs    are    masked.       As    we    depend    chiefly 


158  ANAESTHESIA 

upon  the  muscular  signs  and  the  respiration,  it  is  safer  to 
allow  the  patient  to  "  come  out  "  now  and  then  to  the  point 
of  a  slight  spasm  of  the  respiration  than  to  keep  him 
"  deep  "  all  the  while. 

The  Indications  for  Intrapharyngeal  Insufflation 

1.  Operations  on  the  head  and  neck  excluding  intra- 
nasal operations ;  glands  of  the  neck,  tonsils  and  adenoids ; 
tumors  of  the  face;  intraoral  operations.  In  operations 
for  hare  lip  and  cleft  palate,  the  vapor  may  be  delivered  by 
one  catheter  through  the  intact  nostril. 

2.  Whenever  the  immediate  proximity  of  the  anaesthe- 
tist endangers  the  asepsis  of  the  field  of  operation,  as  in 
upper  abdominal  operations ;  breast  operations ;  operations 
on  the  shoulder  or  chest. 

Contraindications 

When  the  percentage  method  of  intrapharyngeal  in- 
sufflation is  employed,  the  method  may  be  used  in  any  type 
of  case  with  the  possible  exception  of  the  very  young  and 
those  patients  who  have  double  nasal  obstruction,  or  who 
are  to  suffer  nasal  manipulations. 

When  the  variable  method  by  air  bulb  or  oxygen  is 
used,  the  method  is  contraindicated  in  all  cases  which  do  not 
specifically  demand  the  method.  This  is  because  this  varia- 
ble type  depends  much  more  on  the  signs  exhibited  by  the 
patient  for  even  progress  of  the  anaesthesia  than  does  the 
constant  or  percentage  type.  In  these  cases,  since  we  are 
unable  to  constantly  follow  the  eye  signs  and  the  color,  we 
are  working  at  a  disadvantage  which,  when  avoidable, 
should  not  be  incurred. 


ETHER  ANESTHESIA  159 

III.  INTRATRACHEAL  INSUFFLATION 
In  intratracheal  insufflation  we  deliver  ether  vapor 
directly  into  the  trachea  of  the  patient,  usually  at  a  short 
distance  from  its  bifurcation.  We  do  not  intend  by  this 
method  to  supplant  the  normal  respiratory  efforts  by  an 
artificial  respiration,  but  to  deliver  the  ether  in  a  position 
most  available  for  use  by  the  patient.  Instead  of  having  two 
tubes  delivering  vapor  into  the  pharynx,  as  is  the  case  in 
the  pharyngeal  method,  we  have  one  long  tube  delivering 
vapor  into  the  trachea,  past  the  site  of  the  vocal  cords  and 
upper  air  passages,  where  obstruction  to  the  resj)iration  is 
prone  to  occur. 

We  provide  neither  the  inspiratory  nor  the  expiratory 
effort.  By  placing  our  vapor  directly  into  the  rigid  res- 
piratory tree,  beyond  all  obstruction,  under  a  positive 
pressure  of  from  20  to  30  mm.  of  mercury,  we  naturally 
make  inspiration  easy  for  the  patient.  This  is  evident  in 
the  shallow  respirations  which  he  experiences.  By  using 
a  tube  of  a  much  smaller  diameter  than  the  glottis,  we  pro- 
vide for  the  free  esca^DC  of  the  expirations  and  any  excess 
vapor  admitted.  We  do  not  here,  as  in  intrapharyngeal 
insufflation,  use  concentrated  ether  vapor,  diluting  this  with 
the  atmospheric  air,  but  we  give  a  volume  sufficient  for  all 
the  respiratory  needs  of  the  patient.  This  volume,  under 
sufficient  pressure,  is  such  that  even  during  the  inspiration 
with  the  glottis,  but  partially  obstructed  by  the  tube,  no  at- 
mospheric air  will  enter ;  there  will  be  no  inward  flow  at  any 
time  into  the  trachea  along  the  sides  of  the  tube.  On  the 
contrary,  there  should  be  a  constant  flow  to  the  outside. 
This  flow  will  naturally  be  less  at  the  time  of  inspiration 
but  it  will  never  altogether  cease  except  when  the  delivery 
is  cut  off. 


160  ANAESTHESIA 

If  this  idea  of  a  constant  flow  out  of  the  lungs  is  under- 
stood, then  the  great  value  of  this  method  will  be  seen  in 
cases  suffering  from  hemorrhage  or  vomitus  in  the  upper 
respiratory  tract.  We  might  imagine  such  an  anaesthetized 
patient  entirely  immersed  in  water  and  yet  receiving  none  in 
his  respiratory  tree.  Sufficient  pressure  (20-30  mm.  Hg) , 
is  necessary,  not  only  for  the  exclusion  of  atmospheric  air 
but  in  order  to  prevent  the  lungs  from  collapsing  when  the 
intrathoracic  pressure  is  withdrawn  during  operations  in 
the  thorax. 

The  lungs  are  normally  distended  by  virtue  of  the  nega- 
tive pressure  in  the  thoracic  cavity.  This  appears  to  be  due 
to  the  fact  that  these  structures  remain  smaller  than  the 
thorax  in  the  course  of  development.  The  negative  pres- 
sure may  also  be  represented  by  the  natural  elasticity  of 
the  lungs.  If  the  pleural  cavity  is  opened  and  this  elas- 
ticit}'  allowed  to  act,  the  lungs  will  collapse.  The  pressure 
varies  from  4.5  mm.  at  expiration  to  7.5  at  inspiration. 

Obviously  then,  if  we  are  delivering  vapor  into  the 
trachea  at  a  pressure  of  20  mm.  when  the  chest  is  opened, 
the  lungs  will  have  a  tendency  to  expand  rather  than  to 
collapse.     This  is  what  actually  occurs: 

Since  the  lungs  do  contract  at  regular  intervals  during 
normal  respiration,  we  should  simulate  this  action  by  fre- 
quently releasing  the  positive  pressure.  We  do  this  in 
practice. 

Since  the  interchange  of  the  gases  in  the  lungs  results 
chiefly  from  diffusion  rather  than  from  actual  replacement, 
a  constantly  changing  stream  of  oxygenated  vapor  in  the 
trachea  and  large  bronchi  will  serve  the  vital  purposes  of 
respiration.  We  may  then,  with  the  greatest  benefit,  em- 
ploy this  method  in  artificial  respiration  (see  page  29)  where 
free  diffusion  is  present  in  the  lung  tissue,  that  is  in  those 


ETHER  ANESTHESIA 


161 


cases  where  fluid  is  absent,  drowning  cases,  etc.,  excluded. 
In  the  normal  case,  liowever,  it  is  unsafe  to  continue  the 
administration  in  the  face  of  suspended  respiration. 


Fig.  87. — Portable  an8e.<!thetometer.    (Connell.) 

Apparatus. — 

1.  Connell's  an^esthetometer. 

2.  Intratracheal  catheter. 

3.  Larj^ngoscope  and  mouth  prop. 

1.  The  ana?sthetometer  (Fig.  87)  has  ah-eady  been  men- 
11 


162 


ANAESTHESIA 


tioned  on  page  62  and  in  connection  with  intrapharyngeal 
insufflation  on  page  1.50  et  seq. 

2.  The  intratracheal  catheter  (Fig.  88).  The  best 
tube  is  the  ordinary  silk-woven  urethral  catheter  {size  £4- 
French)  with  a  side  openi^ig  iiear  its  end.  The  diameter 
of  the  catheter  should  be  less  than  one-half  the  diameter  of 
the  glottis.     A  mark  should  be  made  26  cm.  from  the  tip. 


FiG.  SS. — Intratracheal  catheter. 

This  mark  indicates  the  limit  to  which  the  catheter  ma}^ 
be  introduced.  This  mark  should  not  be  permitted  to  pass 
the  incisor  teeth.  In  the  normal  patient  such  a  catheter 
introduced  this  distance  will  be  about  .5  cm.  above  the  bifur- 
cation of  the  trachea.  As  a  rule  it  will  be  found  that  the 
tube  must  be  pushed  once  again  the  distance  between  the 
incisor  teeth  and  the  glottis. 


ETHER  ANAESTHESIA 


163 


3.  The  Jackson  laryngoscope  has  proven  entirelj^  effi- 
cient (Fig.  89).  This  instrument  affords  a  direct,  electri- 
cally illuniiiiated  view  of  the  glottis.  By  this  inspection 
we  are  enabled  to  estimate  the  size  of  the  catheter  necessary 
and  to  introduce  it  with  full  knowledge  that  it  is  in  the 
trachea  and  not  in  the  cesophagus.      The  laryngoscope, 


Fig.  89. — Jackson  laryngoscope  and  rheostat . 

which  contains  a  small  dry  battery  in  the  handle,  is  the  most 
convenient  pattern. 

The  mouth  prop  (Fig.  88)  is  for  the  purpose  of 
protecting  the  catheter  from  accidental  injury  as  it  lies 
between  the  upper  and  lower  incisor  teeth. 


164  ANAESTHESIA 

The  Administration. — Preliminary  preparation : 
{a)    Place  half  a  dozen  silk- wound  urethral  catheters, 
each  marked  26  cm.  (10-1/2  inches  from  the  tip)  in  a  pan 
of  ice-water. 

{b)  Start  the  ana?sthetometer  so  that  it  is  delivering 
50  mm.  vapor  tension.  See  that  the  emergency  gauge 
which  releases  all  pressure  over  20  mm.  Hg  is  in  good 
w^orking  order.  Regulate  the  pressure  between  18  and  20 
mm.  of  Hg. 

(c)  Have  a  foot  bellows  at  hand  for  an  emergency 
(Fig.  79). 

(d)  See  that  the  electric  lamp  in  the  laryngoscope  is 
in  good  condition. 

In  order  to  successfully  administer  an  anaesthetic  by  the 
method  of  intratracheal  insufflation  it  is  essential  that  anaes- 
thesia be  completely  induced  by  the  oral  method.  The 
semi-open  or  close  drop  method  may  be  employed.  If  in- 
tubation be  attempted  before  the  larynx  has  become  anaes- 
thetized, spasm  will  supervene,  which  will  prevent  satis- 
factorj^  maintenance  by  this  method. 

The  technic  of  intubation  is  as  follows:  The  patient, 
having  been  well  anaesthetized  (lid  reflex  gone,  jaw  re- 
laxed, eyeballs  fixed,  pupils  contracted  or  slightly  dilated, 
corneal  reflex  gone  in  both  eyes,  and  the  light  reflex  slug- 
gish in  the  presence  of  a  good  color  and  stertorous  respira- 
tions), and  lying  on  his  back  flat  on  the  table,  the  head  is 
grasped  by  the  right  hand  and  forcibly  extended  so  that 
the  chin  is  almost  on  a  straight  line  with  the  sternum  and 
neck  (Fig.  90).  The  laryngoscope  is  grasped  in  the  left 
hand,  as  shown  in  the  illustration.  It  is  then  slipped  over 
the  now  dependent  upper  aspect  of  the  tongue  until  the 
epiglottis  is  brought  into  view.  The  lip  of  the  instrument 
is  then  slipped  over  this  and  the  base  of  the  tongue  thus 


ETHER  ANAESTHESIA 


165 


elevated.  The  glottis,  well  illuminated  by  the  small  elec- 
tric lamp  at  the  distal  end  of  the  instrument,  is  now  in  full 
view  (Fig.  91).  With  tlie  laryngoscope  still  grasped  in 
the  hand,  we  select  a  catheter  of  the  proper  size  with  our 
right  and  slip  this  through  the  laryngoscope  into  the  glottis, 
up  to  the  26  cm.  mark.  A  liissing  of  air  tln-ough  this  will 
now  follow.  The  patient  often  coughs  more  or  less  vio- 
lently depending  upon  the  completeness  of  his  induction. 


Fig.  90. — Intratracheal  Anaesthesia.  The  patient  is  in  the  dorsal  position  and  the  operator  is 
forcibly  extending  the  head  preliminary  to  exposure  of  the  larynx  by  the  Jackson  laryngo- 
scope which  he  holds  in  his  left  hand.  Jackson  technic.  Roosevelt  Hospital  Report,  1915. 
(Courtesy  of  Dr.  L.  Booth.) 

This  quickly  passes  off,  however,  and  regular  breathing  is 
quietly  resumed.  As  the  catheter  passes  into  the  trachea, 
a  hissing  of  air  through  it  will  be  heard.  This  is  a  guaran- 
tee that  the  catheter  is  properly  placed.  When  this  sound 
is  not  heard,  one  should  suspect  that  the  tube  has  slipped 
into  the  oesophagus.  The  mouth  prop  is  now  placed  in 
position,  the  catheter  running  through  it  and  the  delivery 


166  ANAESTHESIA 

tube  from  the  machine  attached  to  this.  The  situation  now 
resembles  the  intrapharyngeal,  after  the  dehvery  through 
the  nasal  tubes  has  begun.  Our  duties  are  also  the  same 
with  the  exception  that  we  must  interrupt  the  flow  two  or 
four  times  a  minute  by  pinching  the  tube.  We  also  watch 
the  pressure  very  carefully  and  observe  with  particular 


Fig.  91. — Intratracheal  ansesthesia.  The  larynx  is  exposed  to  view  by  inserting  the  laryn- 
goscope under  the  tongue  and  epiglottis  and  forcibly  lifting  these  structures.  When  the  larynx 
is  in  plain  view,  the  catheter  is  introduced  as  is  shown  in  the  photograph.  Jackson  technic. 
Roosevelt  Hospital  Report.     (Courtesy  of  Dr.  L.  Booth.) 

care  the  respiratory  movements  of  the  patient.  With  this 
form  of  anaesthesia  properly  administered  the  maintenance 
is  ideal. 

We  anticipate  obstruction  to  the  respiration.  We 
deliver  a  constant  vapor  of  sufficient  concentration  in  a 
volume  equal  to  all  the  respiratory  needs  of  the  patient. 

The  stage  of  recovery  must  be  delayed,  since  the  com- 
pletion of  the  first  half  of  this  stage,  namely  the  complete 


ETHER  ANESTHESIA  167 

return  of  the  reflexes,  cannot  be  permitted  while  the  tube 
is  in  the  trachea.  Following  the  withdrawal  of  the  tu})e  a 
certain  degree  of  acapnia  results  from  the  excessive  venti- 
lation which  has  been  carried  on,  thus  inducing  a  diminished 
CO2  content  in  the  blood. 

After-sickness  is  the  exception.  There  is  seldom,  if 
ever,  any  evidence  of  irritation  to  the  vocal  cords  due  to 
friction  by  the  catheters,  even  though  the  latter  have  been 
in  contact  with  these  structures  for  two  hours  or  more. 

Trouble. — 1.  The  chief  difficulty  will  be  found  to  be 
the  introduction  of  the  tube.  Three  factors  are  necessary 
to  obviate  this  trouble: 

1.  Deep  aneesthesia  before  intubation  is  attempted. 

2.  Complete  extension  of  the  head. 

3.  Direct  vision  of  the  glottis. 

2.  A  catheter  too  large  in  diameter  thereby  obstructing 
the  return  flow  or  introduced  too  far,  i.e.,  into  the  bronchus, 
which  it  may  j^artly  or  completely  occlude,  will  subject  the 
lung  to  destructive  pressure.  If  there  is  doubt  as  to  the 
proper  position  of  the  catheter  this  may  be  partially  with- 
drawn, then  introduced  until  it  strikes  an  obstruction,  i.e., 
the  bifurcation  of  the  trachea,  when  it  is  again  withdrawn 
an  inch. 

3.  The  tube  may  have  entered  the  oesophagus;  in  this 
case  the  respirations'  do  not  whistle  through  it. 

4.  The  pressure  should  not  only  be  regulated  by  a  blow- 
off  but  should  be  constantly  readable  on  a  Hg.  manometer. 

5.  The  ansesthetometer  may  of  course  get  out  of  order 
and  the  punip  may  stop,  which  difficulties  must  be  antici- 
pated and  properly  met. 

The  method  is  neither  dangerous  nor  difficult  when  one 
understands  the  object  to  be  achieved  and  when  one  is 
familiar  with  the  apparatus  which  he  is  to  use. 


168  ANESTHESIA 

The  reader  will  doubtless  conclude  that,  however  ideal 
this  method  may  be,  it  is  debarred  from  the  possibility  of 
ever  becoming  a  routine  method  for  all  types  of  cases, 
because  of  the  technic  and  the  complicated  apparatus 
involved. 

Broadly  sjDcaking  we  may  say  that  for  hospital  work, 
where  the  anajsthetometer  has  been  installed,  the  question 
of  apparatus  may  be  ignored.  One  becomes  familiar  with 
this  modified  gas-meter  and  ceases  to  be  surprised  at  its 
accuracy  and  constancy.  Real  trouble  is  quite  exceptional 
and  when  it  does  occur  one  feels  as  when  one's  watch  stops. 
The  only  thing  to  do  is  to  have  it  fixed.  We  have  nothing 
else  which  will  give  us  results  which  are  so  unvarying. 

The  crux  of  the  whole  question  is  the  intubation  and  its 
advisability  or  inadvisability.  The  theory  and  the  practice 
of  this  procedure  will  certainly  form  obstacles  to  the  fre- 
quent and  widespread  use  of  this  method. 

The  Advantages  of  Insufflation  by  the  Intra- 
tracheal Method 

1.  Sj)ecifically  indicated  in  intratracheal  operations,  in 
order  to  prevent  the  collapse  of  the  lung. 

2.  In  intraoral  operations,  excision  of  the  tongue,  re- 
moval of  the  lower  jaw,  cleft  palate,  etc. 

3.  In  operations  on  the  trachea  and  the  larynx. 

4.  For  operations  about  the  head  and  neck  in  general. 

5.  When  vomitus  may  collect  in  the  upper  air  passages, 
as  in  emergency  operations  for  intestinal  obstruction. 

The  Disadvantages 

1.  A  special  knowledge  of  technic  is  necessary. 

2.  Complicated  and  costly  apparatus  are  needed. 

3.  Deep  anaesthesia  must  be  induced  before  the  tube 
may  be  introduced. 


ETHER  ANESTHESIA  169 

IV.    THE  ADMINISTRATION  OF  THE  ANESTHETIC 
PER  RECTUM 

We  have  considered  the  most  commonly  used  and  the 
most  practical  forms  of  administering  the  anjesthetic  hy 
the  indirect  method,  namely  oral,  pharyngeal  and  intra- 
tracheal insufflation. 

The  chief  reason  for  the  effectiveness  and  safety  of  this 
route  lies  in  the  enormous  capillary  surface  exposed  to  the 
action  of  the  anaesthetic  vapor.  This  surface  has  been  es- 
timated as  being  equal  to  an  area  of  90  square  meters  or 
equal  to  the  surface  presented  bj^  a  balloon  twentj'^  feet  in 
diameter. 

It  is  possible,  however,  to  induce  and  maintain  anses- 
thesia  by  the  injection  of  a  suitable  solution  into  the 
rectmii. 

This  method  while  ap]3arently  simj)le  is  yet  so  fraught 
with  danger  that  its  use  should  be  restricted  to  the  expert 
anaesthetist.  It  should  be  employed  only  in  the  face  of 
special  and  urgent  indications,  such  as  bronchoscopy  or 
where  it  is  impossible  to  secure  a  proper  intratracheal 
apparatus. 

Ether  may  be  given  per  rectum  when  olive  oil  or  oxy- 
gen is  used  as  a  vehicle. 

Oxygen  ether  vaj)or  per  rectum  has  been  used  inter- 
mittently for  the  last  ten  or  fifteen  years.  With  this 
method  it  is  not  practical,  however,  to  induce  ana\sthesia. 
Its  chief  value  is  for  the  maintenance  of  anaesthesia  other- 
wise induced.  Since  we  have  other  and  better  methods  of 
maintaining  anaesthesia,  it  Avill  be  of  little  value  to  enter 
more  fully  into  a  discussion  of  this  rather  obsolete  method. 

Anaesthesia  by  the  injection  of  olive  oil  and  ether,  how- 
ever, will  require  a  somewhat  more  lengthy  consideration. 


170  ANESTHESIA 

This  method,  introduced  during  the  last  two  years,  while 
certainly  attractive  from  several  points  of  view,  is  perni- 
cious because  of  its  apparent  simplicity.  To  give  an  enema 
of  a  mixture  of  ether  and  olive  oil,  which  will  result  in  sat- 
isfactory surgical  anaesthesia,  appears  so  simple  upon 
superficial  consideration  that  thoughtless  ansesthetists  have 
naturally  been  attracted  and  without  counting  the  cost 
have  not  only  endangered  but  killed  their  patient, 

A  technic  of  such  apparent  simplicity,  as  is  described 
for  the  proper  administration  of  this  method,  should  have 
no  intricacies  into  which  the  unwary  may  blunder.  A 
method  demanding  experience  and  great  care  should  be 
safeguarded  by  the  immediate  report  of  fatalities  directly 
or  remotely  due  to  the  method. 

The  small  surface  which  the  gut  offers  for  the  absorp- 
tion of  the  ether  vapor  implies  the  need  of  a  concentrated 
solution  placed  i?i  situ  and  necessarily  absorbed  slowly. 
This  solution  when  once  introduced  into  the  rectum  passes 
more  or  less  completely  out  of  our  control. 

The  rate  at  which  this  vapor  is  thrown  off  by  the  lungs  in 
the  human  being  will  differ  from  that  in  the  small,  hairy  animals, 
whose  respiratory  mechanism  is  intended  to  dispose  of  a  propor- 
tionally much  larger  amount  of  heat  and  moisture  than  does  the 
human. 

Observations  made  upon  cats  and  rabbits  involving  the 
element  of  respiration  will  not  form  a  reliable  basis  upon 
wJiich  to  judge  human  beings. 

As  long  as  we  are  obliged  to  depend  upon  the  reliability 
of  colon  irrigation  to  remove  an  overdose,  and  upon  the 
dilution  of  the  circulation  by  an  intravenous  solution  when 
the  former  has  proven  ineffective,  we  should  approach  this 


ETHER  ANAESTHESIA  171 

method  with  the  utmost  caution.  Until  we  may  consider 
statistics  from  the  unreported  deaths  due  to  this  method, 
our  pohcy  in  the  ahsence  of  urgent  indications  and  expert 
<,'ontrol  should  be  one  of  ''  watchful  icaiting." 

While  we  are  aware  of  excellent  results  which  have  fol- 
lowed the  use  of  this  method,  we  feel  that  it  is  not  adapted 
for  routine  use:  certainly  not  for  the  tyro  and  the  occa- 
sional anaesthetist. 

Apparatus.— 

1.  Eight-ounce  measuring  glass. 

2.  Olive  oil  and  ether. 

3.  Catheter  and  rubber  tubing. 

4.  Funnel. 

We  take  the  liberty  of  following  here  the  directions 
^iven  by  Dr.  Gwathmey,  the  originator  of  the  oil  method. 

Preliminary  treatment:  Castor  oil  the  night  before, 
followed  in  the  morning  by  warm  water  enemas,  one  hour 
apart  until  the  return  is  clear.  The  patient  may  then  be 
allowed  to  rest  for  two  or  three  hours. 

One  hour  before  operation  5  to  20  grs.  of  chloretone  in 
supjDository  form  are  given;  for  the  chlorotone  we  may 
substitute  2  to  4  drachms  of  paraldehyde  in  an  equal 
amount  of  olive  oil. 

Twenty  minutes  before  operation  a  hyj^odermic  of  1/12 
to  1/4  grs.  of  morphine  and  1/200  to  1/100  gr.  of  atropine 
may  be  given. 

The  Solution. — Adults  are  given  a  mixture  consisting 
of  ether  Oz.  6,  olive  oil  Oz.  2  (  a  75  per  cent,  mixture ) .  The 
size  of  the  dose  is  reckoned  upon  a  basis  of  Oz.  1  of  the 
mixture  to  every  20  lbs.  of  body  weight ;  i.e.,  man  weighing 
140  lbs.  would  need  Oz.  7. 

Children  are  given  a  mixture  consisting  of  ether  Oz.  3, 


172  ANiESTHESIA 

olive  oil  Oz.  3  (a  50  per  cent,  mixture).     The  size  of  the 
dose  is  reckoned  as  with  adults. 

The  Administration. — With  the  patient  in  the 
Simms'  position  (see  Fig.  21),  in  his  own  bed,  the  catheter 
(24  F.)  is  introduced  about  four  inches  into  the  rectum. 
The  oil  ether  mixture  is  then  allowed  to  flow  in,  allowing  at 
least  one  minute  for  each  ounce. 

The  patient  quickly  becomes  drowsy.  Ether  appears 
on  the  breath  in  from  five  to  ten  minutes.  Excitement  may 
be  moderate  or  entirely  absent.  After  a  time,  ten  to  thirty 
minutes  according  to  the  absorptive  power  of  the  colonic 
mucous  membrane  of  the  patient  in  question,  he  may  be 
placed  on  the  stretcher  and  conveyed  to  the  operating  room. 
The  stage  of  maintenance  is  controlled  by  increasing 
or  decreasing  the  freedom  of  the  respiration,  i.e.^  a  towel 
over  the  face  will  cause  the  patient  to  sink  into  deeper  nar- 
cosis by  virtue  of  the  rebreathing  of  the  expired  ether.  On 
the  other  hand,  a  throat  tube  (see  Fig.  14),  will,  by  in- 
creasing the  freedom  of  the  respiration  and  consequently 
the  amount  of  the  ether  thrown  off,  lower  the  level  of  the 
maintenance. 

Occasionally  one  is  obliged  to  supplant  the  rectal  ad- 
ministration by  the  drop  method.  If  the  respiration  should 
show  signs  of  shallowness  or  failure,  the  ether  and  oil 
injected  should  be  immediately  withdrawn  by  reintroduc- 
ing the  catheter  and  allowing  the  retained  solution  to  run 
off.  In  the  event  of  failure  of  the  respiration,  rebreath- 
ing of  CO2  may  be  beneficial.  If  ineffective  it  is  recom- 
mended that  a  vein  be  opened  and  from  1000  to  2000  cc. 
of  normal  saline  injected  with  a  hope  of  reducing  the  ether 
tension  in  the  ansesthetized  tissue.  When  the  operation  is 
well  under  wav  it  has  been  found  advisable  to  withdraw 


ETHER  ANESTHESIA  173 

as  much  of  the  injection  as  may  he  reached  with  the  cathe- 
ter. At  the  completion  of  the  operation  a  cokl  soapsuds 
enema  is  intrcxhiced  hi<>li  into  the  colon.  This  is  then 
drawn  off  and  two  to  four  ounces  of  olive  oil  are  introduced, 
with  a  view  of  neutralizing  any  ether  which  may  remain 
unexcreted. 

The  Advantages  of  the  Method 

When  efficient,  the  nature  of  the  induction  in  the  pa- 
tient's hed  is  certainly  a  great  boon. 

The  apparatus  is  most  simple  and  economical  (this  for 
many  is  the  "  raison  d'  etre  ") . 

The  control  when  effective  is  most  simple,  i.e.,  increas- 
ing the  freedom  of  the  res2)iration  by  a  tube  to  lighten  the 
amesthesia,  decreasing  it  by  a  towel  over  the  face  to  deepen 
it. 

When  the  intratracheal  method  is  not  available  this 
method  may  be  used  with  satisfaction  for  operations  on 
the  oral  passages,  the  nasal  passages  and  the  neck. 

The  Disada^antages  of  the  Method 

1.  It  is  certainly  dangerous. 

2.  The  preliminary  preparation  is  frequently  inefficient 
and  often  distresses  the  patient. 

3.  The  method  is  unreliable,  even  in  the  hands  of  the 
experienced  and  must  often  be  supplemented  by  oral  in- 
sufflation. 

4.  The  addition  of  an  anaesthetic  by  mouth  in  addition 
to  that  in  situ  in  the  rectum  is  more  than  ordinarily  danger- 
ous, as  we  do  not  know  what  part  of  the  latter  will  be 
suddenly  absorbed. 

5.  Distention  of  the  rectum  is  prone  to  occur. 

6.  It  is  undesirable  in  cases  where  the  Trendelenburg: 


174  ANAESTHESIA 

position  is  used  (Fig.  18),  as  the  injection  has  a  tendency^ 
to  force  its  way  up  the  gut  hy  gravity. 

7.  Injections  which  are  producing  untoward  effects 
frequently  cannot  be  recovered.  We  doubt  the  possibihty 
of  completely  irrigating  the  colon  at  will. 

8.  Ulcerations  of  the  colon  and  operations  about  the 
lower  gut  positively  contraindicate  the  use  of  this  method. 

9.  The  respiration  may  form  a  vicious  circle,  i.e.,  the 
more  ether  absorbed  the  more  shallow  the  respirations  are 
likely  to  become ;  the  more  shallow  the  respirations  the  more 
ether  accumulates  in  the  circulation. 

10.  Since  the  ether  which  is  not  broken  up  by  the  body 
tissues  must  be  excreted  by  the  lungs,  we  doubt  the  effi- 
ciency of  this  method  in  pulmonary  tuberculosis. 

11.  Ninety  per  cent,  of  the  injections  into  the  rectum 
find  their  way  to  the  csecum  by  virtue  of  reverse  peristal- 
sis.    Can  we  recover  such  injections  at  will? 

12.  Cases  which  present  respiratory  obstruction,  obese 
individuals,  goitre  cases,  etc.,  would  appear  to  contrain- 
dicate this  method,  as  such  obstruction  interferes  with  our 
chief  safety  valve,  the  freedom  of  the  respiration. 

13.  Emergency  cases  necessarily  lacking  the  proper 
preliminarj^  perparation  are  unsuited  to  this  method. 

14.  The  untoward  effects  of  morphine  in  cases  having 
received  a  rectal  injection  of  a  solution  of  ether  are  more 
difficult  to  combat. 

V.    THE  DIRECT  METHOD  OF  ANESTHETIZATION 
BY  INTRAVENOUS  ANESTHESIA 

Intravenous  anaesthesia  is  that  type  of  anaesthesia  in 
which  we  introduce  into  the  circulation  of  the  patient,  by 
way  of  a  convenient  vein,  a  solution  which  contains  ether^ 


ETHER  AXiESTHESIA  175 

The  strength  of  tliis  sohition  varies  from  .5  to  7  per  eent. 
The  amount  of  the  sohition  a(hninistered  depends  upon  the 
duration  of  the  anaesthesia.  This  amount  is  from  500  to 
3.500  ec,  1000  ec.  an  hour  being  the  average.  The  solution  is 
given  continuously,  no  accumulative  action  being  permitted. 
We  do  not,  as  is  the  case  with  rectal  anaesthesia,  give  a  dose 
and  trust  to  the  patient  to  absorb  it  or  excrete  it  according 
to  our  expectations,  depending  upon  enemas  to  undo  mis- 
chief after  it  has  occurred.  When  one  ceases  to  adminis- 
ter the  intravenous  solution,  the  patient  "  comes  out  "  at 
once.  The  control  is  delicate  and  free  from  many  of  the 
complications  which  one  is  prone  to  meet  in  insufflation 
methods. 

We  speak  of  intravenous  anaesthesia  as  the  direct 
method  of  anasthesia  because  by  this  method  we  do  not 
require  the  assistance  of  an  intermediary  system,  such  as 
the  respiratory  or  the  gastro-intestinal  to  assist  us  in  our 
anasthetization.  We  place  our  anasthetizing  agent 
directly  into  the  blood  stream,  through  which  medium  it 
presumably  acts  upon  the  central  nervous  system.  From 
the  point  of  view  of  the  anasthetic,  then,  the  method  is 
direct. 

From  the  point  of  view  of  the  anasthetist,  however,  tlie 
matter  is  not  so  simple.  The  proper  introduction  of  the 
solution  implies:  (1)  satisfactory  local  anasthesia  for  the 
isolation  of  the  vein  of  introduction;  (2)  a  surgical  opera- 
tion (the  introduction  of  the  cannula). 

The  speedy,  skillful  and  painless  administration  of  an 
intravenous  injection  implies  familiarity  with  surgical  tech- 
nic.  Such  a  procedure  requires  perfect  asepsis  and  dex- 
terity bred  of  experience.  While  the  average  anasthetist 
might  succeed  in  finding  a  vein  in  most  cases  and  in  success- 


176  ANAESTHESIA 

fully  introducing  a  cannula  in  a  smaller  number,  the 
chances  of  his  doing  so  rapidly  and  painlessly  would  be  less. 

This  type  of  anaesthesia  may  be  classed  as  an  anaesthetic 
feat  and,  while  most  attractive  in  many  of  its  aspects,  will 
never  achieve  a  broad  practicability.  It  will  be  of  interest, 
however,  to  consider  the  method  and  to  become  familiar 
with  the  essentials  of  the  technic. 

Apparatus. — 1.  Accessories  for  local  anaesthesia  (see 
page  257). 

2.  Instruments  for  isolating  vein. 

3.  Apparatus  by  means  of  which  the  solution  is  deliv- 
ered to  the  patient. 

4.  The  solution  administered. 

5.  Apparatus  for  maintaining  free  respiration. 

1.  The  accessories  for  the  production  of  local  anaesthe- 
sia consist  of  a  proper  syringe,  needles  and  solution.  A 
detailed  description  of  these  various  elements  will  be  found 
under  the  consideration  of  local  anaesthesia,  page  257. 

2.  The  instruments  necessary  for  the  isolation  of  the 
vein  consist  of  a  scalpel,  two  haemostats,  blunt  pointed  scis- 
sors, ordinary  forceps  and  a  pair  of  small  artery  forceps. 

3.  Apparatus  for  the  intravenous  solution  proper  con- 
sists of: 

(a)  A  reservoir,  preferably  glass,  having  a  capacity  of 
2000  cc.  with  an  outlet  in  the  bottom. 

(b)  Tubing  whose  proximal  end  is  attached  to  the  res- 
ervoir and  whose  distal  end  terminates  in  a  small  cannula, 
which  is  to  be  introduced  into  the  vein. 

(c)  An  arrangement  whereby  one  can  readily  and  con- 
stantly estimate  the  amount  and  rate  of  flow  of  the  solution 
into  the  vein  is  essential.  In  the  apparatus  shown  in  Fig. 
92,  this  is  done  by  means  of  a  specially  constructed  glass 


ETHER  ANAESTHESIA 


177 


globe  through  which  the  solution  is  made  to  flow  on  its 
way  from  the  reservoir  to  the  cannula.  This  globe,  known 
as  a  dropper,  is  an  indispensable  feature  of  the  apparatus, 
for  the  rate  of  flow  of  the  solution,  about  16  cc.  per  minute, 
must  be  constantly  indicated.  The  action  of  tlie  dropper 
is  as  follows :  When  the  solution  is 
flowing,  it  enters  the  upper  part  of 
the  globe  in  the  form  of  a  spray  or 
drop  through  a  small,  nipple-like 
projection.  This  is  allowed  to  col- 
lect in  the  lower  half  of  the  globe, 
the  control  being  established  by  a 
clip  attached  to  the  distal  tubing. 
The  constancy  with  which  this  level 
is  kept  in  the  presence  of  a  continu- 
ous flow  through  the  nipple  indi- 
cates the  flow  to  the  patient. 

4.  The  solution,  a  5  to  7.5  per 
cent,  solution  of  ether  in  sterile 
Ringlers  solution  (a  solution  con- 
taining sodium,  potassium  and  cal- 
cium chloride),  or  in  ordinary 
normal  saline,  at  a  temperature  of 
8.5"  F. 

.5.  A  pharyngeal  tube. 

The  Administration. — It  is 
quite  essential  that  the  usual  pre- 
liminary treatment,  as  indicated  in  the  section  covering  tlie 
control  of  the  period  of  excitement,  page  24-,  be  carried  out. 
The  preliminary  visit  is  especially  valuable  for  the  bene- 
ficial effect  of  suggestive  therapeutics.  The  patient  must 
be  brought  into  tlie  operating  room  and  placed  on  the 

12 


Fio.   92. — Intravenous  apparatus. 


178  ANAESTHESIA 

table  half  an  hour  before  the  time  set  for  the  operation. 
Incidentally  this  means  that  the  operating  room  must  be 
set  and  the  anaesthetist  on  hand  some  three-quarters  of  an 
hour  to  an  hour  before  the  time  set  for  operation. 

When  the  patient  has  been  placed  on  the  table,  a  hypo- 
dermic of  morphine  grs.  Yb  and  atropine  1/100  and  scopo- 
lamine 1/1000  is  administered.  The  arm  to  receive  the 
solution  is  strapped  to  the  support  upon  which  it  rests. 
The  veins  of  the  forearm  are  made  to  stand  out  promi- 
nently by  digital  pressure  above  the  elbow.  A  space  as  big 
as  a  dime  is  injected  with  novocaine  .5  per  cent.  The  skin 
is  incised  and  the  vein  exposed  and  dissected  out.  While 
this  procedure  is  being  accomplished,  the  reservoir  is  filled 
with  the  solution  and  placed  on  the  stand  8  feet  above  the 
floor.  The  vein  having  been  isolated,  a  ligature  tied  dis- 
tally  and  an  united  ligature  placed  proximally  to  the  open- 
ing made  therein,  the  cannula  with  the  solution  flowing  is 
gently  introduced  and  secured  by  the  loose  ligature,  which 
is  now  tied  with  one  knot.  A  large  gauze  pack  is  now 
placed  over  the  field  and  strapped  to  the  arm  with  adhesive 
plaster. 

We  may  then  devote  our  attention  to  the  indicator 
and  the  patient. 

The  solution  is  allowed  to  flow  slowly  into  the  vein. 
The  patient  soon  passes  into  a  quiet  sleep  with  little  or  no 
excitement.  The  transition  from  consciousness  to  the  stage 
of  maintenance  is  indeed  so  quiet  that  one  would  be  led  to 
suspect  that  ana?sthesia  was  not  present  were  it  not  for  the 
loss  of  the  lid  and  eye  reflexes.  The  airway  must  be  patent 
at  all  times.  This  is  best  accomplished  by  the  introduction 
of  the  Connell  tube  as  soon  as  the  pharyngeal  reflexes  have 
disappeared.    Anaesthesia  is  increased  (the  level  of  main- 


ETHER  ANAESTHESIA  179 

tenance  raised)  by  increasing  the  flow  of  the  solution,  the 
patient  is  allowed  to  "come  out"  (the  level  of  mainte- 
nance is  lowered)  by  stopping  the  flow.  It  is  more  satis- 
factory to  keep  up  a  continuous  flow  than  to  give  the  solu- 
tion intermittently,  since  the  patient  recovers  j^romptly 
upon  the  cessation  of  the  flow.  The  amount  of  the  solution 
usually  consumed  in  an  hour  is  1000  cc. 

PosT-OpERATI^^E  Treat:ment. — The  wound  in  the  arm 
should  be  closed  with  a  straight  needle.  It  may  then  be 
wiped  with  iodine  solution  or  carbon  tetrachloride  in  thy- 
mol (50  per  cent,  solution),  and  the  dressing  applied. 

The  patient  should  be  placed  in  the  semi-Fowler  posi- 
tion ( Fig.  122 ) ,  and  he  should  be  turned  every  hour  to  over- 
come the  tendency  to  pulmonary  oedema  and  the  formation 
of  spots  resembling  bruises  in  the  loose,  fatty  tissue  of  the 
back  and  buttocks. 

The  Advantages  of  the  Method 

Ideal  control  of  the  administration. 

Not  dependent  upon  the  rate  or  the  depth  of  the 
respiration. 

The  minimum  amount  of  the  amesthetic  is  employed. 

There  is  little  or  no  cunmlative  action. 

The  technic  is  sufficiently  complicated  to  exclude 
thoughtless  experimentation. 

The  Dis.\dvaxtages 

The  general  anaesthetic  must  be  preceded  b}"  an  opera- 
tion under  local  anaesthesia. 

The  jDreliminaries  to  the  administration  of  the  ana?s- 
thetic  per  se  involve  a  loss  of  much  time  and,  from  this 


180  ANESTHESIA 

point  of  view,  the  method  is  impractical  as  a  routine  in  the 
large  hospital. 

The  proper  administration  implies  familiarity  with  the 
surgical  teehnic  required. 

The  blood  pressure  is  raised. 

The  bleeding  is  increased  and  the  fluid  has  a  tendency 
to  collect  in  the  abdomen. 

It  is  an  open  question  as  to  the  harm  done  by  the  injec- 
tion of  a  normal  saline  solution  in  the  blood  stream  of  a 
healthy  individual. 

The  possibility  of  septic  thrombosis  must  be  considered. 

There  is  a  tendency  to  pulmonary  oedema  and  spots, 
resembling  bruises,  frequently  appear  on  the  back  and 
buttocks. 


CHAPTER  V 
ETHYL  CHLORIDE 

Ethyt-  cliloride,  or  sweet  sjDirits  of  salt,  was  discovered 
by  Florens  in  1847.  It  is  a  colorless  liquid,  very  volatile 
and  has  a  pungent,  ethereal  odor.    It  boils  at  12.5  C. 

Ethyl  chloride  is  used  for  general  anaesthesia  as  well  as 
for  local  anfusthesia.     (See  page  249.) 

While  ethyl  chloride  has  been  frequently  employed  as 
a  general  antesthetic  throughout  the  stages  of  induction^ 
maintenance  and  recovery,  its  use  as  the  sole  anaesthetic  in 
such  a  complete  arucsthesia  should  be  discouraged.  This 
is  because  of  the  narrow  margin  of  safety  between  a  stage 
of  satisfactory  maintenance  (complete  muscular  relaxa- 
tion) and  the  lethal  dose  or  the  dose  which  may  kill.  Col- 
lapse is  more  liable  to  follow  ethyl  chloride  than  any  other 
anesthetic. 

From  a  practical  point  of  view  then  the  administration 
of  this  ansesthetic  is  limited  to:  (1)  the  induction  of  anaes- 
thesia (as  a  preliminary  to  ether  anaesthesia)  ;  (2)  incom- 
plete ancesthemi  (that  type  of  anaesthesia  without  the  stage 
of  maintenance) . 

The  administration  of  ethyl  chloride  as  a  preliminary 
to  ether,  and  its  use  alone  for  short  operations,  is  but  a 
matter  of  degree.  With  the  former  our  object  is  to  destroy 
consciousness;  with  the  latter  we  go  a  step  further  and 
apj)roach  the  period  of  relaxation. 

Ethyl  chloride  is  frequently  used  as  a  substitute  for 
N2O.  Portability  and  cheapness  are  offered  as  reasons  for 
this.  In  view  of  the  un(|uestionably  greater  safety  of  X^O, 
however,  such  a  j^rocedure  is  entirely  unjustifiable.  The 
situation  is  well  put  by  Thomas  D.  Luke,  who  says  "  The 

181 


182 


ANiESTHESIA 


idea  has  got  about  among  a  large  number  of  both  the  medi- 
cal and  dental  profession  that  ethyl  chloride  is  a  sort  of  a 
glorified  N-O,  which  one  may  carry  about  in  one's  waist- 
coat 230cket  and  administer  to  all  and  sundry,  without  any 
special  precaution  or  skill  on  the  part  of  the  administra- 
tor .  .  .  Nothing  further  from  the  facts  could  be  imagined 


Fig.  93. 


Fig.  94. 


Fig.  9.3. — Chloroform  containers. 

Fig.  94. — Ethyl  chloride  container,  spray  type. 

Its  highly  toxic  character  and  the  danger  due  to 
the  great  rapidity  of  its  action  should  be  fully  recognized 
as  well  as  its  admirable  proj)erties  as  an  adjuvant  to  chloro- 
form and  ether."  Dr.  Luke  follows  his  remarks  with  a 
report  of  twenty-three  deaths  from  ethyl  chloride  in  the 
short  span  of  five  years. 


ETHYL  CHLORIDE  183 

The  administration  of  ethyl  chloride  is  often  followed 
by  headache,  nausea  and  vomiting.  These  symptoms  may 
appear  immediately  after  recovery  or  he  delayed  for  five 
or  six  hours. 

When  ethyl  chloride  is  administered,  the  consciousness 
is  rapidly  lost  as  with  N2O.  Its  effects  are  best  seen  with 
a  closed  apparatus,  as  with  ether.  In  overdose  it  kills 
quickly,  as  does  chloroform. 

A  cork  or  some  other  mouth  prop  must  be  placed 
between  the  teeth  before  the  administration  is  begun,  for 
masseteric  spasm  is  prone  to  occur. 

When  a  closed  apparatus  is  used  the  dose  should  not 
exceed  1.5  cc.  for  children  and  3  to  4  cc.  for  adults.  This 
dose  should  be  given  slowly  and  cautiously. 

When  open  or  semi-open  methods  are  used,  the  dose 
may  be  increased. 

Ethyl  chloride,  owning  to  its  very  great  tendency  to 
evaporate,  is  marketed  in  special  glass  containers.  (See 
Fig.  94.)  The  delivery  from  some  containers  is  controlled 
by  a  spring  lever  applied  to  the  vent,  in  others  by  a  gas- 
tight  screw  cap. 

The  Administration  of  Ethyl  Chloride  as  a  Pre- 
liminary TO  Ether  Anaesthesia  or  Alone  for  the 
Purpose  of  Securing  Incomplete  Anesthesia 

Apparatus. — The  semi-open  drop  mask,  as  described 
on  page  128,  or  a  closed  apparatus  such  as  described  on 
page  134. 

When  the  semi-open  method  is  employed  a  much  larger 
quantity  of  the  drug  will  be  required. 

Before  starting  the  anaesthetic  a  mouth  prop  is  placed 
between  the  teeth  of  the  patient;  the  mask  is  then  arranged 
as  in  Fig.  69  or  Fig.  71,  and  the  patient  is  instructed  to 


184  ANESTHESIA 

count  out  loud.  Ethyl  chloride  is  carefully  sprayed  upon 
the  mask.  The  administration  is  continued  until  conscious- 
ness is  lost,  when  ether  in  the  form  of  a  drop  or  spray  is 
resorted  to. 

The  effects  obtainable  by  this  method  are  not  nearly 
as  satisfactory  as  those  which  may  be  secured  by  the  em- 
ployment of  a  closed  method.  Where  the  latter  is  em- 
ployed, the  rebreathing  bag  is  filled  with  the  patient's 
expirations.  He  is  then  instructed  to  breathe  naturally  to 
and  fro.  As  he  does  so,  ethyl  chloride  is  sprayed  into  the 
apparatus  through  some  convenient  vent;  either  into  the 
bag  proper,  or  into  the  evaporating  mediums,  gauze,  wire 
screen,  or  whatever  it  may  be.  The  drug  is  added  slowlj^ 
not  more  than  4  cc.  in  all  being  used. 

Free  air  should  be  administered  upon  the  first  evidence 
of  stertor. 

When  ethyl  chloride  is  given  per  se  to  produce  incom- 
plete anaesthesia,  it  should  not  be  pushed  to  a  loss  of  the 
corneal  reflex  and  a  dilated  pupil.  An  absent  lid  reflex, 
page  103,  deep,  involuntary  respirations  and  absence  of 
muscular  excitement  being  all  that  is  desired. 

When  employed  as  a  preliminary  to  ether,  we  have 
attained  our  object  when  consciousness  is  lost  and  the 
pharyngeal  reflex  has  been  rendered  somewhat  less  sensi- 
tive to  tlie  odor  of  ether. 

The  loss  of  consciousness  when  ethyl  chloride  is  used 
for  induction  is  not  so  rapid  or  so  pleasant  as  when  NoO 
is  used.  It  is,  however,  more  speedy  and  more  grateful 
to  the  patient  than  is  ether  alone. 

The  dangers  of  this  anaesthetic  are  twofold:  From 
overdose ;  from  asphyxia,  secondary  to  spasm  occurring  in 
the  respiratory  tract. 

The  proper  anticipation  of  these  difficuties  will  fore- 
stall untoward  results. 


CHAPTER  VI 

CHLOROFORM 

Chloroform  was  first  used  as  an  anfesthetlc  by  Sir 
James  Simpson  in  1847,  some  months  after  the  announce- 
ment of  the  discovery  of  ethyl  chloride  by  Florens. 

Chloroform  is  a  colorless  liquid  with  a  sweet  but  burn- 
ing taste,  and  possessed  of  an  ethereal  odor.  The  boiling 
point  is  61.2  C. 

GENERAL  CONSIDERATIONS 

Since  its  discovery  chloroform  has  been  the  favorite 
anesthetic  of  continental  Europe.  Ether,  however,  has 
found  greater  favor  in  this  country,  more  particularly  in 
the  large  cities.  In  country  practices  and  small  towns  in 
the  United  States,  chloroform  is  still  extensively  employed. 

With  chloroform  the  stage  of  induction  is  usually  free 
from  excitement;  the  stage  of  maintenance  is  quiet  and 
characterized  by  tranquil  breathing  and  complete  relaxa- 
tion. The  stage  of  recovery  is  comparatively  brief  and  the 
after-effects  of  the  anaesthetic  are  usually  conspicuous  by 
their  absence. 

Chloroform,  however,  unlike  ether,  is  a  distinct  pro- 
toplasmic poison.  Chloroform  Jiills  quickly  in  overdose 
(in  a  concentration  of  5  per  cent,  or  more) .  Chloroform  is 
most  dangerous  during  the  stage  of  induction,  at  which 
time  it  is  most  commonly  used. 

As  a  protoplasmic  poison,  the  evil  effects  of  chloro- 
form frequently  do  not  become  evident  until  some  time 
after  the  administration.  Such  late  effects  are  known  as 
"  delayed  chloroform  poisoning."     This  condition  of  de- 

185 


186  ANESTHESIA 

laved  chloroform  poisoning  is  now  well  recognized.  The 
degenerative  effects  which  take  place  closely  resemble  those 
found  in  the  liver  and  kidneys  of  eclamptic  cases.  Nmner- 
ous  investigators  have  pointed  out  these  lesions.  We  quote 
the  following  from  a  paper  by  Drs.  E.  B.  Cragin  and  E.  T. 
Hull  of  the  Sloane  Maternity  Hospital: 

"  Recent  studies  of  the  pathologic  changes  produced 
by  eclampsia,  delayed  chloroform  poisoning  and  chloro- 
form ana?sthesia  have  shown  a  striking  similarity  in  the 
findings  in  all  three  conditions." 

The  pathologic  picture  in  each  is  that  of  congestion, 
hemorrhage,  degeneration  and  necrosis.  Our  knowledge 
of  the  pathology  of  eclampsia  is  of  comparatively  recent 
date,  but  thanks  to  the  work  of  Jurgens,  Schmorl, 
Williams,  Ewing,  Welch  and  others,  the  lesions  are  now 
well  recognized  and  generally  accepted. 

Delayed  chloroform  poisoning  as  such  has  been  fre- 
quently recognized  and  carefully  studied,  both  clinically 
and  pathologically,  for  the  last  twenty  years.  Many  writers 
have  reported  series  of  fatal  cases,  all  showing  symptoms 
and  lesions  which  are  now  recognized  as  typical  of  the  con- 
dition. A  number  of  these  deaths  occurred  after  only 
twenty  or  thirty  minutes  of  anaesthesia,  untoward  symptoms 
developing  a  few  hours  to  a  few  days  after  the  administra- 
tion. The  symptoms  include  progressive  weakness,  pallor 
or  cyanosis,  restlessness,  vomiting-  delirium,  convulsions, 
stupor,  coma  and  death.  The  organs  principally  affected 
are  the  liver  and  kidneys.  The  former  is  yellow  and  fatty, 
with  hemorrhages  often  under  the  capsule  and  through- 
out its  substance.  The  typical  picture  is  that  of  a  central 
necrosis.  The  cells  about  the  central  vein  disappear,  leaving 
only  a  mass  of  granular  material  which  shows  neither  nuclei 


CHLOROFORM  187 

nor  cell  outline.  'Nearer  the  periphery  of  the  lohule  is  a  zone 
of  swollen  cells,  which  have  undergone  hyaline  and  fatty 
degeneration.  A  few  normal  liver  cells  may  remain  at  the 
periphery.  The  kidneys  are  swollen,  markedly  congested, 
with  occasional  hemorrhages  under  the  capsule,  ahout  the 
tuhules,  and  in  the  pelvis.  The  cortex  is  thickened,  the 
markings  indistinct.  JNIicroscopically  the  cells  of  the 
tuhules  are  greatly  swollen,  granular,  and  loaded  with  fat. 
The  lumen  is  filled  with  granular  material,  fat  glohules 
and  coagulated  serum.  The  heart  muscle  often  shows 
some  fatty  degeneration.  The  changes  are  generally  con- 
sidered to  he  more  profound  in  the  liver,  though  some  oh- 
servers  have  found  the  kidney  degeneration  even  more 
marked. 

The  reports  of  these  cases  of  delayed  chloroform 
poisoning  with  their  pathologic  findings  led  naturally  to 
a  study  of  the  lesions  produced  by  chloroform  anaesthesia. 
jVIany  animals  were  used  in  these  experiments,  most  often 
dogs,  rabbits  and  guinea-pigs.  These  studies  were  exhaus- 
tive and  include  the  work  of  Lengemann,  Ostertag,  Stiles 
and  McDonald,  Stassman  and  others,  together  with  the 
more  recent  work  of  Howland  and  Whipple.  The  most 
striking  result  of  these  studies  was  the  extent  of  the  degen- 
eration and  necrosis  found  in  the  liver  and  kidney  after 
chloroform  anaesthesia  of  a  short  duration. 

It  has  been  found  that  characteristic  lesions  are  regu- 
larly produced,  varying  in  degree  with  the  duration  and 
depth  of  anaesthesia,  and  also  with  idiosyncrasy.  Thus 
after  thirty  minutes  to  one  hour  anaesthesia  with  chloro- 
form, the  centres  of  the  lobules  of  the  liver  show  conges- 
tion with  granular  and  fatty  degeneration,  the  innermost 
cells  being  necrotic,  their  nuclei  not  taking  the  stain  and  the 


188  ANAESTHESIA 

protoplasm  being  deeply  stained  pink  with  eosin.  With 
more  prolonged  action  the  changes  approach  those  found 
in  delayed  chloroform  jjoisoning  in  man.  The  liver  ap- 
pears yellow  and  fatty  with  scattered  hemorrhages.  The 
cells  about  the  centres  of  the  lobules  are  entirely  necrotic, 
a  granular  mass  remaining.  Outside  of  this  is  an  area  of 
cells  which  have  undergone  hyaline  and  fatty  degenera- 
tion, with  normal  cells  at  the  periphery.  In  some  cases 
the  liver  cells  have  almost  entirely  disappeared  with  only 
a  few  scattered  living  cells  in  the  portal  spaces.  In  the 
kidney,  chloroform  anaesthesia  causes  a  marked  congestion 
with  a  cloudy  swelling  and  occasionally  hemorrhages  into 
the  parenchyma.  The  cells  of  the  tubules  are  swollen  and 
granular,  occluding  most  of  the  lumen ;  in  other  places  they 
have  disappeared  entirely.  Fatty  degeneration  is  present 
and  in  many  cases  pronounced.  The  heart  muscle  may  be 
pale  and  show  fat  droplets  in  its  fibres.  Hemorrhages 
occur  throughout  the  body,  particularly  in  the  serous  mem- 
branes, and  in  the  intestinal  and  stomach  nmcosa. 

Rowland  and  others  were  able,  almost  at  will,  by  con- 
tinuing the  amesthesia  to  produce  delayed  chloroform 
poisoning  in  dogs,  with  symptoms  and  lesions  correspond- 
ing in  detail  with  those  of  delayed  chloroform  poisoning 
in  man.  Thus  we  find  in  these  three  conditions,  eclampsia, 
delayed  chloroform  poisoning  in  man  and  chloroform  anaes- 
thesia in  animals,  many  similarities.  Pathologically  there 
is  central  necrosis,  parenchymatous  and  fatty  degeneration 
in  the  liver ;  congestion,  parenchymatous  and  fatty  degen- 
eration in  the  tubules  of  the  kidney  and  a  tendency  to 
hemorrhages  throughout  the  body.  Clinically  in  delayed 
chloroform  poisoning  and  in  eclampsia  there  are  vomiting, 
jaundice,  delirium,  convulsions  and  coma. 


CHLOROFORM  189 

Does  ether  produce  lesions  in  the  hver  and  kidneys  simi- 
lar to  chloroform  (  Some  work  has  already  been  done  alono' 
this  line,  notably  by  Handler,  Lengemann  and  Leppmann, 
and  it  was  partly  to  confirm  scattered  observations  on  this 
subject  that  a  further  study  of  ether  amcsthesia  was 
undertaken. 

In  our  experience  six  mongrel  dogs  of  medium  size 
were  given  ether  by  inhalation  from  an  open  cone.  They 
were  killed  with  ether  forty-eight  hours  after  the  last  anses- 
thesia  and  autopsied  at  once.  Sufficient  ether  was  given 
to  produce  complete  nmscular  relaxation  with  loss  of 
corneal  reflex. 

In  none  of  these  animals  could  any  necrosis  in  any  of 
the  parenchyma  be  found.  In  the  lungs  occasional  small 
areas  of  a  deeper  red  than  the  surrounding  substance,  con- 
taining an  increase  in  the  amount  of  blood  on  section, 
showed  congestion.  The  heart  muscle  in  each  dog  was 
found  to  be  of  normal  color,  striations  distinct,  no  appar- 
ent increase  in  fat. 

There  were  no  hemorrhages  in  the  mucosa  of  the 
stomach  and  intestines. 

The  livers  were  of  a  good  color  throughout,  the  vessels 
in  a  few  places  standing  out  a  brighter  red  than  the  sur- 
rounding structure.  The  yellow  appearance  was  entirely 
lacking,  the  cells  throughout  preserved  their  outlines  with 
contents  intact.  There  was  no  suggestion  of  necrosis  at 
any  point.  The  protoplasm  was  somewhat  granular  and 
small  droplets  of  fat  were  found  in  the  cells  about  the 
central  veins  and  in  the  portal  spaces.  This  fat  was  only 
slightly  in  excess  of  that  in  the  controls. 

The  kidneys  were  of  normal  size,  capsule  not  adherent, 
cortex  not  thickened,  markings  distinct.     jNIicroscopically 


190  ANAESTHESIA 

the  cells  of  the  tubules  were  well  preserved  throughout; 
their  outlines  were  distinct,  the  nuclei  staining  sharply, 
the  protoplasm  granular,  the  tubules  containing  in  some 
places  some  granular  material.  Fat  globules  were  present 
in  a  few  of  the  straight  tubules  and  in  the  lining  cells. 
This  condition  seemed  no  more  than  is  normally  found, 
and  no  more  marked  than  in  the  controls  taken. 

No  pathologic  changes  could  be  found  in  any  of  the 
sections  of  pancreas  and  spleen.  These  facts  seem  to 
demonstrate  that  in  animals,  at  least,  ether  23roduces  prac- 
tically little  etfect  on  the  liver  and  kidneys  as  compared 
with  the  very  marked  changes  in  these  organs  produced  by 
chloroform,  and,  while  it  may  be  argued  that  this  compari- 
son has  been  demonstrated  only  in  animals,  the  similarity 
between  the  lesions  of  delayed  chloroform  poisoning  in 
man  and  chloroform  ana?stliesia  in  animals  makes  it  appear 
more  than  probable  that  reasoning  as  to  the  effect  of  ether 
on  the  liver  and  kidney  of  man,  from  the  lesions  produced 
by  ether  in  animals,  is  entirely  justified. 

The  foregoing  facts  lead  to  the  conclusions  arrived  at 
by  the  Committee  on  Amtsthesia  of  the  American  Medical 
Association,  June  loth,  1912: 

"  1.  The  use  of  chloroform  as  the  anaesthetic  for  major 
operations  is  no  longer  justifiable.  Scientific  investigation 
and  clinical  experience  agree  in  demonstrating  that  necro- 
sis of  the  liver  ( '  delayed  chloroform  poisoning  ' )  follows 
in  a  by  no  means  inconsiderable  percentage  of  cases.  The 
mode  of  causation  of  this  sequel  is  unknown.  There  are 
therefore  no  precautions  that  can  be  intelligently  taken 
against  it.  Accordingly  the  surgeon  whose  patient  dies 
in  this  manner  a  day  or  two  after  operation  must  face  the 
responsibility  of  having  knowingly  taken  an  unnecessary 


CIILOROF(JUM  191 

chance — and  lost.  We  see  no  reason  to  believe  that  in 
respect  to  toxicity  there  is  more  than  a  sli<>ht  (juantitative 
difference  between  chloroform  alone  and  such  chloroform 
mixtures  as  A.  C.  E.,  anesthol,  etc. 

"  2.  For  minor  operations  also  the  use  of  chloroform 
should  cease.  In  general  it  may  advantageously  be  re- 
placed by  nitrous  oxide,  or  nitrous  oxide-oxygen.  It  is  a 
mistake  to  think  that  a  fatality  under  antesthesia  is  neces- 
sarily due  to  an  unusually  large  administration  of  the 
anaesthetic.  A  previous  condition  of  suffering  or  anxiety, 
or  a  prolongation  of  the  stage  of  antesthesia  excitement 
renders  a  subject  who  would  otherwise  be  able  to  resist  a 
large  dosage,  liable  to  collapse  even  under  a  small  dosage. 
The  practical  importance  of  avoiding  so  far  as  possible 
all  anxiety  and  pain  has  been  demonstrated  on  the  clin- 
ical side  by  Crile,  and  experimentally  by  Henderson.  It 
is  noteworthy  that  Levy  (with  Cushny)  has  recently 
demonstrated  that  in  cats  a  sudden  heart  failure  (fibrilla- 
tion) is  induced  by  a  period  of  light  chloroform  anjtsthe- 
sia,  while  this  form  of  death  is  not  inducible  by  deep 
anesthesia.  Risks  of  this  sort  are  far  greater  with  chloro- 
form than  with  ether,  and  greater  with  ether  than  with 
nitrous  oxide.  As  they  cannot  be  foreseen,  they  cannot  be 
avoided,  except  by  replacing  a  dangerous  anaesthetic  by 
a  safe  one. 

"  3.  Chloroform  is  sometimes  found  convenient  for  initi- 
ating ana?sthesia  in  alcoholics  or  other  difficult  subjects. 
As  a  means  of  avoiding  the  ill  effects  of  a  prolonged  period 
of  ether  excitement  the  temporary  employment  of  chloro- 
form for  this  j^urpose  is  j^erhaps  sometimes  the  lesser  of 
two  evils.  It  is  justifiable  only  when  nitrous  oxide  is  not 
available.  If  chloroform  is  to  be  so  used,  it  sliould  be 
given  as  soon  as  it  is  evident  that  the  j)atient  will  not  go 


192  ANyESTHESIA 

under  ether  readily.  Unless  the  change  to  chloroform  is 
made  early  it  should  not  be  made  at  all.  We  wish  espe- 
cially to  emphasize  the  point  that  chloroform  should  never 
under  any  circumstances  be  administered  after  a  pro- 
longed period  (10  or  15  minutes  or  more)  of  ether  excite- 
ment. Even  a  small  administration  of  chloroform  is  then 
peculiarly  liable  to  induce  respiratory  or  cardiac  death. 
As  soon  as  full  anaesthesia  is  attained  ether  should  be 
substituted." 

It  has  been  argued  that  the  evil  effects  of  chloroform  are 
largely  due  to  impurities  found  in  the  drug ;  these  impuri- 
ties depending  upon  faulty  preparation  or  exposure  to 
light  and  air.  If  such  toxic  impurities  are  so  constantly 
present  as  to  result  in  the  common  findings  of  a  large  num- 
ber of  investigators,  it  would  seem  that  the  end  result  is 
the  same  as  though  the  evil  lay  in  the  drug  itself.  We  can 
scarcely  hope  to  convince  all  users  of  chloroform  of  the 
danger  of  their  position  and  urge  upon  them  a  favorite 
preparation  of  our  own.  If  chloroform  is  shown  to  be  con- 
sistently poisonous  we  had  best  forego  the  pleasure  of  its 
free  usage  and  confine  ourselves  to  an  anaesthetic  which  is 
safer,  though  somewhat  more  difficult  of  manipulation. 

We  who  have  become  accustomed  to  chloroform  will 
be  prone  to  yield  ourselves  to  its  charms  and  to  feel  that 
because  clinical  distress  seldom  appears,  pathological 
damage  has  not  occurred.  We  will  recall  particularly  our 
rather  extensive  experience  in  obstetrical  cases,  the  delight- 
ful and  efficient  anaesthesia  which  we  have  so  often  ob- 
tained, the  freedom  from  excitement  in  induction  and  the 
absence  of  symptoms  upon  recovery.  We  will  recall  the 
many  instances  in  which  we  have  anaesthetized  children 
large  and  small.    We  are  prone  to  smile  when  the  pathol- 


CHLOROFORM  193 

ogist  condemns  our  most  valuable  agent  "  chloroform." 
We  will  not  abandon  chloroform  but  we  will  use  it  less 
frequently  and  with  more  respect. 

Those  of  us  who  are  now  receiving  our  obstetrical  train- 
ing will  find  little  difficulty  in  getting  along  without  this 
valuable  but  dangerous  agent.  The  present  generation 
brought  up  upon  a  constant  diet  of  pathological  findings 
learn  to  look  with  increasing  confidence  to  this  authority. 
We  accept  its  dictates  as  our  own  and  confidently  walk 
in  the  light  of  its  decisions.  If  we  accept  the  conclusions 
of  pathology,  chloroform  per  se  cannot  be  the  anaesthetic 
of  choice  in  the  routine  case. 

The  indications  which  present  themselves  for  the  use  of 
chloroform  must  be  sufficiently  urgent  to  overcome  our 
aversion  to  its  use.  The  chief  indication  is  that  presented 
by  acute  pulmonary  disease  where  N-O  and  O  is  not  availa- 
ble, and  in  the  control  of  individuals  who  cannot  be  well 
handled  by  ether. 

One  of  the  most  marked  characteristics  of  chloroform 
is  its  tendency  to  bring  about  circulatory  depression.  In 
glancing  over  the  works  of  Hewitt,  Luke  and  other  Englisli 
authors,  one  is  struck  with  the  frequent  reference  to  cir- 
culatory shock.  We  scarcely  ever  see  a  case  of  this  nature 
where  ether  is  the  ana?sthetic.  The  use  of  ether  with  chloro- 
form appears  to  reduce  the  likelihood  of  this  type  of  shock. 
This  explains  in  part  the  popularity  of  the  well  known  A. 
C.  E.  mixture  (alcohol  1,  chloroform  2,  ether  3).  The 
alcohol  of  this  mixture  is  usually  omitted,  the  result  being 
a  C.  E.  mixture. 

The  C.  E.  mixture  is  so  much  safer  than  the  chloroform 
2)er  se  that  it  has  largely  supplanted  the  employment  of 
the  latter. 

13 


194  ANiESTHESIA 

Containers. — Since  chloroform  deteriorates  upon  ex- 
posure to  air  it  is  safer  not  to  use  a  sample  which  has  been 
opened  (Fig.  93).  With  this  fact  in  mind  manufactories 
are  now  putting  out  ampules  and  bottles  sufficient  for  one 
administration.  Bottles  containing  one  ounce  are  inexpen- 
sive and  satisfactory.  If  the  solution  is  not  all  used  the 
residue  should  be  sent  to  the  jDharmacy  for  the  preparation 
of  chloroform  liniment. 

The  Administration. — Since  the  addition  of  ether  to 
the  chloroform  reduces  the  likelihood  of  circulatory  depres- 
sion and  improves  the  quality  of  the  respiration  we  have 
practically  abandoned  the  use  of  chloroform  per  se. 

Ether  may  be  given  mixed  with  chloroform  in  the  pro- 
portion of  ether-parts  3,  chloroform-parts  2,  or  the  drugs 
may  be  given  alternately  by  the  drop  method.  A  few 
drops  of  chloroform  being  followed  by  a  somewhat  larger 
amount  of  ether.  Where  one  is  desirous  of  obtaining  the 
effects  of  chloroform,  more  particularly  for  the  stage  of 
induction,  the  contents  of  an  ounce  bottle  of  chloroform 
freshly  opened  is  mixed  with  one  and  one-half  bottles  of 
ether  (the  empty  chloroform  bottle  being  the  measure) . 

As  the  stage  of  maintenance  is  approached,  ether  is 
added  to  the  container,  one  ounce  at  a  time.  By  the  time 
the  stage  of  maintenance  has  been  entered  upon  the  amount 
of  chloroform  present  in  the  mixture  will  be  so  small  as  to 
be  practically  negligible. 

Apparatus. — When  the  C.  E.  mixture  is  employed  it 
may  be  administered  to  the  patient  by:  («)  the  drop 
method;  {h)  the  vapor  method. 

(«)  When  chloroform  alone  is  used  there  should  be  no 
air  restriction  whatever.  For  this  reason  the  use  of  the 
semi-open  method  and  the  closed  method  should  not  be 


CHLOROFORM  195 

tolerated.  The  open  drop  mask,  as  described  on  page  122, 
may  be  employed.  If  chloroform  alone  is  used  the  mask 
should  not  be  i3ermitted  to  rest  against  the  face.  Where 
the  C.  E.  mixture  is  the  anaesthetic,  however,  the  mask  may 
be  used,  as  in  the  case  of  the  open  drop  method  of  ether 
administration.  One  should  always  remember  that  one  is 
administering  chloroform  and  that  it  is  dangerous  to  soak 
the  mask  as  may  be  safely  done  in  the  case  of  ether  jier  se. 
The  mixture  should  be  added  cautiously  drop  by  drop,  the 
signs  of  anjEsthesia  being  our  index  as  to  whether  we  should 
push  or  decrease  the  administration. 

{h)  The  vapor  method  is  a  very  convenient  and  effec- 
tive method  of  administering  the  C.  E.  mixture.  Oxygen 
is  preferable  to  air  as  a  means  of  producing  the  vapor. 
The  same  care  should  be  exercised  as  in  the  case  of  the 
drop  method.  As.  antesthesia  progresses  ether  may  be 
added  to  the  reservoir,  thereby  reducing  the  risk  of  chloro- 
form complications.  Chloroform  should  never  be  given 
near  a  naked  flame.  A  product  known  as  phosgen  gas  is 
formed  which  may  seriously  effect  not  only  the  patient 
but  the  operator  and  assistants  as  well. 

The  Causes  of  Death  in  Chloroform  Anaesthesia 

In  the  stage  of  induction  chloroform  deaths  occur  as 
follows : 

(fl)  Spasm  of  the  respiration  occurs.  The  anaesthetist 
continues  to  drop  the  chloroform  upon  the  mask.  A  large 
amount  of  chloroform  thus  accumulates.  Following  the 
relief  of  the  spasm,  sjiontaneous  or  artificial,  the  patient 
breathes  deeply.  A  lethal  dose  of  chloroform  is  carried 
to  the  heart  muscle,  which,  weakened  by  the  previous  res- 


196  ANAESTHESIA 

piratory  spasm,  suddenly  and  permanently  dilates.  This 
is  the  usual  cause  of  death  of  the  large,  alcoholic  and 
athletic  individual. 

(h)  Vagus  inhibition,  causing  paralysis  of  the  heart 
muscle,  sometimes  occurs  in  high  strung,  neurotic  in- 
dividuals. 

In  the  stage  of  maintenance  chloroform  deaths  may 
occur  as  follows: 

(a)  By  the  elevation  of  the  head  and  shoulders  syncope 
may  result,  vi^hich  in  turn  may  develop  into  definite  circu- 
latory shock  and  cessation  of  the  respiration. 

( b )  By  simjjle  overdose. 

In  the  stage  of  recovery  death  may  result  from: 

(a)  Progressive  acidosis  secondary  to  an  acute  sep- 
ticaemia or  from  unrecognized  diabetes. 

Post-operative  death  occurs  as  a  result  of  extensive 
protoplasmic  poisoning  effecting  chiefly  the  liver  and  the 
kidneys. 

Chloroform  fatalities  are  not  likely  to  occur  if  the 
following  suggestions  are  adhered  to: 

If  it  is  excluded  in  cases  of  acute  septicaemia,  acidosis 
and  eclampsia.  If  it  is  invariably  used  with  ether  and  not 
alone. 

If  the  prone  position  is  always  adhered  to.  (Even  the 
position  advised  for  upper  abdominal  closure,  page  43, 
should  be  avoided) . 

If  fresh,  newly  opened  specimens  of  chloroform  are 
used. 

If  the  mask  is  taken  off  the  face  during  masseteric 
spasm. 

If  the  corneal  reflex  is  always  retained,  and  a  lustreless, 
dilated,  fixed  pupil  never  permitted. 

If  the  rhythm  of  the  respiration  is  maintained,  and  the 


CHLOROFORM  197 

administration  changed  to  straight  ether  upon  the  first 
sign  of  inexphcable  shallowness  or  irregularity. 

When  the  heart  stops  in  chloroform  it  usually  does  so 
as  a  permanently  damaged  organ.  Its  dilation  is  toxic 
rather  than  mechanical,  hence  the  difficulty  of  resuscitation. 
The  blood  in  the  coronary  arteries  nmst  be  squeezed  out 
manually  to  relieve  the  condition.  Massage  of  the  heart 
through  the  diaphragm  even  though  it  calls  for  a  special 
laparotomy  should  be  done ;  for  death  under  these  circum- 
stances is  a  most  dreadful  thing.  Who  would  refuse  a 
laparotomy  upon  himself  in  such  an  extremity?  Trans- 
pleural pericardiotomy  for  massage  of  the  heart  may  also 
be  practised.  There  is  some  hope  of  success  even  though 
the  heart  has  ceased  to  beat  for  ten  minutes. 

Lieb  has  suggested  that  the  radial  artery  be  imme- 
diately exposed.  A  cannula  delivering  the  saline  ordi- 
narily employed  for  intravenous  injections,  at  a  height  of 
four  feet  above  the  artery  is  introduced  and  when  the  flow 
into  the  artery  actually  begins,  inject  directly  through  the 
rubber  tubing  next  to  the  cannula  ten  minims  of  adrenalin. 
This  dose  may  be  repeated  four  or  five  times. 

Artificial  respiration  by  negative  and  by  positive  ven- 
tilation should  always  be  done  (page  91) . 

The  Signs  of  Anaesthesia  when  the  C.  E.  Mixture  is 
THE  Anesthetic 

When  chloroform  is  used  alone  a  condition  of  pseudo- 
relaxation  or  natural  sleep  is  likely  to  follow  especially  in 
children.  When  the  C.  E.  mixture  is  employed  this  does 
not  occur. 

The  patient  must  invariably  be  anaesthetized  in  the 
prone  position. 


198  ANiESTHESIA 

Induction. — Excitement  much  less  than  when  ether  is 
used  alone. 

Rigidity  of  shorter  duration. 

Belajcation  more  easily  accomjDlished. 

Besjnration  regular,  moderately  deep,  increased  in 
rapidity,  becoming  stertorous.  More  shallow  than  with 
ether  alone. 

Eyes. — Globes  rolling  vertically  or  horizontally  (as  in 
ether).  Pupils:  A  pin-point  pupil  is  suggestive  of  light 
anaesthesia,  otherwise  pupils  are  like  ether  pupils.  Corneal 
reflex:  Active  as  in  ether.  Light  reflex:  Active  as  in 
ether. 

Color. — Pallor  characteristics  of  chloroform  per  se. 
With  the  C.  E.  mixture  the  color  approaches  that  of  ether. 
Pallor  is  suggestive  of  circulatory  shock. 

RehidYition. — Lid  relaxation  somewhat  sooner  than 
with  ether.  iVIasseteric  relaxation  somewhat  sooner  than 
with  ether.  If  spasm  occurs  the  anaesthetic  should  be  dis- 
continued at  once  and  not  resumed  until  the  breathing  is 
free. 

Pulse. — The  quality  of  the  pulse  must  be  carefully 
observed.  Circulatory  depression  will  give  a  small  pulse 
of  poor  tension  accompanied  by  pallor  of  the  face. 

M  A I  N  T  E  N  A  N  c  E. — Respiration. — Moderate  stertor. 
More  shallow  and  not  so  rapid  as  with  ether  alone.  Regu- 
lar rhythm  must  be  preserved.  The  regularity  of  the 
respiration  is  the  most  important  sign  of  chloroform 
aneesthesia,  as  failure  of  the  respiration  invariably 
precedes  cardiac  failure. 

Color. — Pale.  Cyanosis  must  not  be  tolerated.  If  the 
percentage  of  ether  used  be  increased  a  better  color  will 
result. 


CHLOROFORM  199 

Eyes. — Globes  fixed,  lustrous.  Pupils  about  normal  or 
slightly  enlarged.  Ij'ght  reflex  present,  sluggish.  Corneal 
reflex  sluggish;   should  not  be  obliterated. 

Relchvaiion. — Lid  reflex  absent.  ]Masseterie  relaxa- 
tion present.     General  "muscular  relaxation  characteristic. 

Pulse. — A  valuable  guide.  Its  tension,  size  and  rapid- 
ity should  be  constantly  observed.  As  a  symptom  of 
the  anaesthesia  j^^f  *<?  it  is  more  important  than  in  ether 
anaesthesia. 

Recovery.- — The  rapidity  of  the  return  of  the  reflexes 
and  latei  the  return  of  consciousness  will  depend  upon  the 
level  at  which  the  stage  of  maintenance  was  carried  and 
upon  the  length  of  the  anessthesia. 

Respiration. — ^Nlore  shallow  than  with  ether. 

Color. — Pallor  normal. 

Eijes. — As  with  ether. 

Muscles. — Generally  relaxed. 

Pulse. — Everything  else  being  equal,  not  so  good  as 
in  ether  anasthesia.  Because  of  its  action  as  j^rotoplasmic 
poison,  chloroform  frequently  gives  rise  to  serious  after- 
sickness,  especially  if  the  administration  has  been  pro- 
tracted. ^^^lere  the  administration  is  brief  and  the  dose 
small,  the  after-effects  are  usually  conspicuous  by  their 
absence. 

Broadly  speaking  we  may  say  that  chloroform  alone 
and  chloroform  given  with  ether  is  contraindicated  in  all 
cases,  except: 

(a)  Acute  pulmonary  disease,  pneumonia,  etc.,  where 
NoO  cannot  be  had. 

{h)  Acute  obstruction  of  the  respiratory  tract,  Lud- 
wig's  angina,  etc. 

((?)  As  a  preliminary  to  ether  anasthesia,  when  N^O 
is  not  available. 


200  ANESTHESIA 

TO  REITERATE 

Chloroform  while  ideal  in  efficiency  is  a  dangerous 
poison.  In  the  light  of  present  day  pathology,  chloroform 
should  cease  to  be  used  as  an  anaesthetic  in  obstetrics. 

Combined  with  ether,  chloroform  is  quite  as  efficient 
and  less  dangerous. 

Chloroform  kills  if  pushed  in  the  face  of  masseteric 
spasm. 

Delayed  chloroform  poisoning  is  a  fact  and  argues  for 
the  complete  replacement  of  the  drug  by  safer  anaesthetic 
agents. 

Chloroform,  if  used  at  all,  should  be  taken  from  a 
freshly  opened  receptacle. 

The  administration  should  invariably  be  performed  in 
the  prone  position. 

The  mortality  of  chloroform  is  variabh^  estimated  as 
1-1000, 1-3000. 


CHAPTER  VII 
NITROUS  OXIDE 

Nitrous  oxide,  laugliing-gas  or  nitrogen  monoxide,  is 
prepared  by  heating  aninioniuni  nitrate  NH4NO3,  the 
result  being  N^O  and  2H2O. 

Nitrous  oxide  is  non-irritating  to  the  respiratory  tract, 
is  possessed  of  a  sweet  taste  and  an  odor  like  that  of  burnt 
sugar.     The  boiling-point  of  liquid  N2O  is  -  90  C. 

Containers. — Nitrous  oxide  is  marketed  as  a  liquid. 
It  is  stored  in  specially  made  vanadium  steel  cylinders, 
(steel  which  will  not  shatter  but  will  simply  split)  whose 
capacity  varies  from  2.5  gallons  to  3200  gallons.  Fig.  95 
shows  various  sizes  of  N^O  cylinders. 

The  pressure  of  the  liquid  gas  enclosed  in  the  cylinder  is 
about  1000  lbs.  to  the  square  inch,  at  room  temperature.  If 
the  cylinders  be  allowed  to  remain  against  a  hot  radiator 
for  some  time  there  is  great  danger  of  explosion  from  the 
increased  pressure.  The  gas  is  draw^n  from  the  cylinders 
by  means  of  a  key  which  opens  a  complex  valve  in  the 
cylinder  head.  These  valves  must  be  operated  cautiously 
or  the  gas  will  escape  with  a  roar  which  wall  badly  frighten 
a  waiting  patient.  When  the  operator  has  only  one  hand 
free  to  manipulate  the  valve  the  cylinder  should  be  pre- 
vented from  rotating  on  its  base  by  some  such  device  as  is 
shown  on  page  209,  Fig.  99.  If  the  gas  does  not  escape 
gradually  when  the  valve  is  opened,  it  is  best  to  work  the 
valve  back  and  forth  before  further  opening.  Occasion- 
ally the  valve  becomes  frozen  and  will  not  permit  of  an 
even  escape  of  the  gas.     If  such  a  valve  is  widely  opened 

201 


202 


ANiESTHESIA 


the  pressure  of  the  gas  will  suddenly  blow  away  the  ob- 
struction with  a  loud  explosion.  The  freezing  of  valves 
in  the  manner  just  mentioned  is  most  likely  to  occur  where 
a  constant  flow  from  the  cylinders  is  sought,  or  when  the 
cylinders  are  in  the  horizontal  instead  of  the  vertical  posi- 
tion.   Specially  designed  reducing  valves,  see  Fig.  96,  pre- 


FlG.   95. — Various  sizes  N2O  tanks,  1UU-32UU  •rallons 


vent  the  possibility  of  the  valves  freezing  and  give  a  con- 
stant, even  flow  of  gas  at  any  desired  rate. 

Estimating  the  Amount  of  Gas  in  a  Cylinder. — 
There  is  one  way,  and  only  one  way,  of  estimating  the 
amount  of  gas  in  a  cylinder  at  any  given  time,  and  that  is 
by  weighing  the  cylinder.     One  will  always  find  a  label 


NITROUS  OXIDE 


203 


pasted  on  the  side  of  the  cylinder  (Fig.  97),  on  which  is 
written : 

The  weight  of  the  cyhnder  full  of  gas. 

The  weight  of  the  cylinder  empty. 

The  difference  in  these  two  weights  represents  the 
weight  of  the  licjuid  N-O  in  the  cylinder.  One  ounce  of 
N2O  is  equal  to  four  gallons  of  the  gas  at  room  temperature 
and  pressure.  The  weight  of  the  liquid  N-O  in  a  full 
100-gallon  cylinder  is  therefore  25 
ounces,  or  one  pound  nine  ounces. 

The  25-gallon  cylinder  is  in- 
tended more  particularly  for  private 
work  where  the  gas  is  desired  for 
induction  only,  the  weight  of  the 
cylinder  and  contents  being  2  pounds. 

The    100-gallon    cylinder    is    the 
size   ordinarily  used.     This   type  of 
cjdinder  is  somewhat  more  cumber- 
some, but  more  dependable  than  is     ^'"^  06.-Reducing  vaive. 
the  smaller  size.     The  weight  of  the  100-gallon  cylinder 
with  contents  is  between  eight  and  nine  pounds. 

The  250-gallon  cylinders  are  intended  for  hospital  use 
where  the  gas  is  freely  employed  not  only  for  inducing 
anaesthesia  but  for  maintaining  it  as  well. 

Some  hospitals  have  become  so  enthusiastic  over  gas 
oxygen  anesthesia  that  they  have  installed  small  plants 
for  the  manufacture  of  the  gas.  At  the  Lakeside  Hos^^ital, 
Cleveland,  a  plant  is  in  operation  which  supplies  all  the 
nitrous  oxide  used  in  the  institution.  Fig.  98  is  a  schematic 
drawing  of  this  plant.  Briefly  the  details  of  the  manufac- 
ture are  as  follows : 

Ammonium  nitrate  in  quantities  of  forty  pounds  at  a 


204 


ANESTHESIA 


time  is  put  into  each  of  two  aluininum  retorts  (a  double  sys- 
tem is  used  so  that  the  pLant  will  not  be  completely  dis- 
abled in  case  of  accident).  This  is  heated  to  400  degrees. 
The  ammonium  nitrate  then  breaks  down  into  N2O  and 
HoO,  which  mixture  is  cooled  by  a  condensing  coil  and 
lead  into  wash  bottles  containing  potassium  permanganate. 


Fig.   97. — Label  on  N2O  cylinder. 

This  treatment  removes  the  oxides.  The  gas  is  then  fed 
into  the  bottom  of  so-called  towers  filled  with  coke.  From 
the  roof  of  these  towers  sodium  hydrate  is  constantly 
sprayed.  This  treatment  removes  any  HNO3  which  may 
be  present.  From  the  top  of  the  tower  the  gas  is  conveyed 
once  more  to  wash  bottles  containing  sulphuric  acid.  This 
treatment  removes  any  free  alkali.    The  gas  is  then  washed 


O  S 

C     z. 


-I  rt 


£.  "5. 


206  ANESTHESIA 

by  passing  through  fresh  water  and  finally  led  to  an  ordi- 
nary gasometer.  When  a  sufficient  bulk  of  gas  has  here 
collected  it  is  compressed  by  a  pump  either  to  liquefaction 
(for  storage  in  small  cylinders  at  a  pressure  of  1500  lbs. 
to  the  square  inch),  or  for  storage  in  large  tanks  at  a  com- 
paratively low  pressure,  about  100  lbs.,  which  is  again  re- 
duced to  about  five  pounds  when  it  is  piped  to  the  operat- 
ing room  to  be  used  as  desired.  When  the  gas  reaches  the 
operating  room  it  passes  through  a  gas  meter  which  checks 
the  amount  consumed.  From  the  meter  it  is  conveyed 
through  heavy  rubber  tubing  to  the  apparatus  which  regu- 
lates the  immediate  flow  to  the  face  piece. 

The  cost  of  the  N2O  is  about  two  cents  a  gallon.  When 
supplied  in  the  25-gallon  cylinders  it  costs  a  little  more; 
when  in  'i-^O-gallon  cylinders  or  larger  the  cost  is  somewhat 
less.  The  actual  cost  of  manufacturing  the  gas  is  small 
once  a  satisfactory  plant  is  established. 

When  buying  the  gas  in  small  quantities,  most  manu- 
facturers require  a  deposit  covering  the  value  of  the  cylin- 
der, this  deposit  being  returnable  upon  the  receipt  of  the 
empty  cylinder.  The  deposit  required  on  the  100-gallon 
cylinder  is  about  $5.00  for  each  cylinder.  Cylinders  con- 
taining N2O  are  usually  painted  black  or  blue  while  those 
containing  oxygen  are  red  or  bronzed. 

General  Considerations. — With  nitrous  oxide  alone  one 
can  obtain  only  an  incomplete  anaesthesia.  The  length  of 
the  administration  is  definitely  limited  by  the  physiological 
reaction  of  the  organism  to  the  drug.  This  reaction  is 
as  follows : 

When  N2O  is  breathed  to  the  total  exclusion  of  air  the 
patient  experiences  a  sense  of  exhilaration.  The  extremi- 
ties tingle  and  quickly  grow  numb.    A  necessity  to  breathe 


NITROUS  OXIDE  207 

or  "  besoin  de  respire  "  makes  itself  felt  and  the  respira- 
tion automatically  becomes  full  and  deep.  Consciousness 
is  completely  lost  in  less  than  half  a  minute  in  the  ordinary 
case.  This  may  be  preceded,  accompanied  or  immediately 
followed  by  flashes  of  light  or  loud  sounds.  Many  patients 
experience  no  sensations  whatever.  If  the  administration 
is  continued,  air  and  oxygen  being  excluded,  the  patient 
rapidly  becomes  pallid,  then  blue  or  gray.  The  nuiscles 
of  the  face  and  limbs  are  thrown  into  convulsions  known 
as  jactitation,  the  respiratory  movements  become  irregu- 
lar and  finally  cease. 

Immediately  upon  the  admission  of  air  the  patient 
resumes  normal  respirations  and  color.  Consciousness 
returns  in  less  than  two  minutes. 

Nitrous  oxide  has  been  administered  hundreds  of  thou- 
sands of  times  to  a  degree  of  partial  asphyxia.  The  pro- 
cedure is  indeed  so  common  among  dentists  and  occasion- 
ally among  house  officers  that  many  men  have  come  to  look 
upon  NoO  ana?sthesia  as  implying  lividity.  It  is  true  that 
in  order  to  obtain  the  longest  "  available  ana?sthesia,"  it  is 
necessary  to  push  gas  to  an  asphyxial  degree  where  oxygen 
is  not  employed.  Such  a  procedure  is  bad  taste  to  say 
the  least,  and  should  not  be  practised.  One  should  manage 
to  get  along  with  a  shorter  anaesthesia,  reapply  the  mask  or 
add  oxygen  to  the  mixture. 

Apparatus. — In  order  to  obtain  satisfactory  results 
an  absolutely  air  tight  apparatus  must  be  employed.  The 
author's  apparatus,  Fig.  72,  offers  a  type  which  is  satis- 
factory. 

Administration. — When  N2O  is  Used  to  Induce 
Ether  Ancesthesia. — This  administration  is  a  routine  pro- 
cedure in  most  large  hospitals.      By  rapidly  and  safely 


208  ANESTHESIA 

destroying  consciousness  the  j^atient  is  spared  a  most  dis- 
tressing experience.  When  we  use  X-O  for  induction  we 
accomplish  two  results : 

1.  We  destroy  consciousness  and  render  the  mucous 
membranes  less  sensitive  to  ether  vapor. 

2.  We  induce  deep  breathing  which  permits  us  to 
rapidly  reach  the  desired  concentration  of  ether  in  the 
patient's  blood. 

Since  hearing  is  one  of  the  last  senses  to  disappear  it  is 
unwise  to  ask  the  patient  whether  or  not  he  is  asleep.  A 
semi-conscious  response  may  result. 

The  bag  of  the  inhaler,  usually  of  two  gallon  capacitj> 
is  filled  with  X'oO.  The  apparatus  is  applied  and  the  pa- 
tient is  instructed  to  breathe  out  naturally  through  the 
mouth.  The  first  three  breaths  may  be  spilled  into  the  air 
by  the  expiratory  valve,  or  rebreathing  may  be  practised 
from  the  start.  Where  the  latter  method  is  employed  re- 
sults are  entirely  satisfactory  and  a  single  bag  of  gas  is 
usually  sufficient.  As  soon  as  the  respirations  have  become 
full  and  deep,  and  evidently  involuntary,  ether  is  very  cau- 
tiously added.  If  the  rhythm  of  the  breathing  is  affected 
it  should  be  withheld  for  a  few  moments  and  then  a  second 
attempt  made.  If  no  hesitation  occurs  the  ether  may  be 
rapidly  increased.  As  soon  as  the  patient  has  received  a 
few  breaths  of  ether,  air  is  added  a  breath  at  a  time.  By 
this  technic  we  have  no  blue  or  even  dusky  patients  at  our 
gas  induction. 

When  Nitrous  Oo'ide  is  Used  Alone. — This  type  of 
administration  is  the  method  usually  employed  in  dental 
work.  When  a  tooth  is  to  be  extracted  a  mouth  prop  of 
cork  or  other  material,  made  especially  for  the  purpose, 
must  be  placed  in  position  before  the  administration  is 


NITROUS  OXIDE 


209 


begun.  The  patient  furthermore  is  ordinarily  in  a  sitting 
position.  The  head  must  not  be  extended  but  should  be 
on  a  straight  line  with  the  body.  The  administration  is 
carried  out  precisely  as  in  the  case  of  NoO  induction  for 
ether  except  that  (oxygen  not  being  used)  we  carry  on 
the  administration  until  slight  jactitation  of  the  arms  or 
legs  takes  place. 

If  ana\sthesia  be  then  discontinued,  a  period  of  available 
anaesthesia  amounting  to  about  fifty  seconds  will  result. 

A  B 


Fig.  99. — The  author's  cylinder  holder.  A,  brass  plate  clamp  for  three  one-hundred  gallon 
Cylinders;  B.pin  screwing  into  plate  and  fitting  in  socket  of  table  clamp;  C,  table  clamp;  D, 
showing  by  dotted  line  the  buried  channel  into  which  the  gas  of  each  cylinder  empties,  all 
leaving  for  face  piece  (not  here  shown)  by  a  single  rubber  tubing. 

During  this  period  any  painful  procedure  may  be  carried 
out,  such  as  the  extraction  of  teeth,  opening  of  abscesses, 
etc.  When  a  longer  anaesthesia  is  desired  with  this  method 
the  face  piece  may  be  reapplied  before  complete  conscious- 
ness returns.  If  the  operation  be  elsewhere  than  in  the 
mouth  one  breath  of  air  should  be  administered  after  every 
four  or  five  breaths  of  rebreathed  N2O.  This  will  give  a 
longer  period  of  available  anaesthesia,  but  does  not  result 
in  anything  like  the  smooth  anaesthesia  offered  })y  tlie  addi- 
tion of  oxygen  gas  to  the  mixture. 

The   author's   clamp   and   cylinder  holder   consist   of 


210 


ANESTHESIA 


two  parts;  the  cylinder  holder  and  a  clamp  for  use  when 
horizontal  support  may  be  had  i.e.,  table,  etc. 

The  cylinder  holder  consists  of  two  parts;  a  nickle- 
plated  brass  plate  about  two  inches  l)y  ten  inches  and  a 
threaded  steel  pin,  which  may  be  screwed  into  the  plate 
and  removed  at  will.  The  plate  is  drilled  so  as  to  receive 
three  cylinders.    Each  hole  has  a  nipple  which  receives  the 


Fig.  100. — The  author's  cylinder  holder  clamped  to  the  edge  of  a  table. 

cylinder  and  a  thumb  screw  which  holds  the  cylinder  in 
place.  This  arrangement  gives  us  the  equivalent  of  three 
yolks  sufficiently  separated  and  rigidly  united. 

The  nipple  which  receives  each  cylinder  is  pierced  by  a 
hole  which  opens  into  a  common  tunnel  made  in  the  plate. 
The  exit  from  this  tunnel  is  from  a  single  vent,  to  which 
the  rubber  tubing  leading  to  the  face  piece  is  attached. 
(Fig.  99.) 


NITROUS  OXIDE 


211 


The  plate,  therefore,  is  the  essential  part  of  the  appara- 
tus and  may  he  used  alone.  When  the  plate  is  used  with- 
out the  elanip  (Fig.  101 ) ,  three  cylinders  are  fitted  into  the 
yolks  and,  thus  united,  are  placed  on  their  sides  and  used 


Fig.   101. — Cylinders  lying  on  a  chair  supported  by  the  author's  holder.    Covered  by  a  blanket 

these  may  be  sat  upon. 

in  this  position.  They  niay  he  placed  on  the  anaesthetist's 
chair  (Fig.  101),  and  when  covered  hy  a  hlanket  form  a 
comfortable  seat. 

The  clamp  consists  of  two  flat  plates  of  steel,  drilled 


212 


ANyESTHESIA 


with  three  holes  each.  Two  of  these  holes  receive  bolts  with 
their  nuts,  the  third  receives  the  pin  which  is  screwed  into 
the  plate  holding  the  cylinders.  This  clamp  fits  over  the 
corner  of  a  table.  The  weight  of  the  cylinders  does  not  in- 
jure the  table  if  the  clamp  is  evenly  applied.     Tables  with 


Fig.   102. — Cylinder  clamp  fastened  to  a  wandow-sill. 

glass  tops  are  not  affected,  as  the  clamp  covers  a  compara- 
tively broad  area.  The  author  has  used  this  clamp  on  the 
lightest  weight,  portable  operating  table  (Fig.  100). 

When  the  patient  is  to  be  moved  from  the  stretcher  to 
the  operating  table,  the  clamp  is  first  fixed  to  the  operating 
table.  The  anesthetic  is  then  started,  either  in  the  ansesthe- 


NITROUS  OXIDE  213 

tizing  room  or  in  the  patient's  bed,  with  the  cylinders  on 
their  sides  on  a  table  or  on  a  chair.  When  the  operating 
room  is  reached,  the  pin  of  the  cylinder  holder  is  conven- 
iently dropjjcd  into  the  holes  of  the  horizontal  plate.  This 
transfer  is  done  easily  and  quietly.  Thus  supported  the 
cylinders  are  completely  out  of  the  way.  They  do  not 
clutter  up  the  floor  space;  are  within  easy  reach  of  the 
anaesthetist  and  move  with  the  movements  of  the  operating 
table. 

The  custom  of  using  nothing  but  a  yolk,  the  cylinder 
standing  on  the  floor,  is  not  only  dangerous  because  of  the 
liability  of  the  cylinders  falling,  but  is  wasteful  of  gas 
because  the  valves  are  often  incompletely  shut  off. 


CHAPTER  VIII 
NITROUS  OXIDE  OXYGEN  ANAESTHESIA 

This  mixture  was  first  employed  by  Dr.  E.  Andrews 
of  Chicago  in  1868. 

The  containers  for  nitrous  oxide  are  described  on  page 
201.  Oxygen  is  put  out  in  cj^inders  containing  10  to  100 
gallons.  This  gas  may  be  compressed  to  the  necessary 
small  bulk  without  being  liquified.  Consequently  there  is 
little  or  no  trouble  with  the  valves  of  the  oxygen  tanks. 
These  containers  are  usually  painted  red  or  bronzed  to 
prevent  the  possibility  of  confusing  them  with  N^O 
cylinders,  which  are  blue  or  black. 

Both  N2O  and  oxygen  tanks  should  be  held  rigidly  by 
some  sort  of  clamp  or  stand,  in  order  that  the  administra- 
tor may  manipulate  the  valves  with  one  hand.  The  most 
simple  clamp  for  this  purpose  is  that  shown  on  page  209. 
This  clamp  has  proven  of  the  greatest  convenience  to  the 
author. 

Two  one-hundred  gallon  X2O  and  one  O  cylinder  may 
be  carried  loose  in  any  handbag  or  dress  suit  case.  At  least 
two  cylinders  of  nitrous  oxide  and  one  cylinder  of  oxygen 
should  always  be  on  hand.  A  simple  and  inexpensive 
stand  and  clamp  for  hospital  use  is  shown  in  Fig.  103. 
This  may  be  easily  made  by  the  hospital  carpenter. 

GENERAL  CONSIDERATIONS 

Perhaps  no  other  type  of  angesthesia  at  the  present  day 
has  received  as  much  attention  as  has  the  combination  of 
gases  popularly  spoken  of  as  gas  oxygen. 

214 


NITROUS  OXIDE  OXYGEN  ANESTHESIA 


215 


Fig.   103. — A  simple  wooden  stand  for  three  cylinders,  suitable  for  hospital  use. 

In  order  to  produce  complete  anaesthetic  effects,  N2O 
must  be  delivered  in  a  concentration  of  about  90  per  cent. 
(The  limits  being  7.5  to  9,5  per  cent.)     If  the  additional 


216  ANESTHESIA 

10  per  cent,  be  replaced  by  air  the  patient  will  suffer  from 
oxygen  starvation  (only  1/5  of  air  being  oxygen).  If, 
however,  the  additional  10  per  cent,  be  supj^lied  by  pure 
oxygen  no  such  asphyxial  result  will  follow.  This  condi- 
tion holds  in  practice  and  explains  the  great  difference 
seen  in  NoO  anaesthesia  with  air,  and  with  oxygen.  The 
difficulty  then  which  confronts  us  in  gas  oxygen  ansesthe- 
sia  is  the  necessity  of  giving  N2O  of  sufficient  concentra- 
tion to  produce  anesthesia,  and  at  the  same  time  supply 
adequate  oxygenation. 

The  permissible  variations  take  place  within  narrow 
limits.  The  aneesthesia  is  induced  quickly  and  recovery 
takes  place  with  astonishing  rapidity. 

The  exceedingly  evanescent  effects  of  the  anaesthetic 
make  it  by  far  the  most  difficult  to  administer.  The  anaes- 
thetist must  not  only  be  constantly  alert  to  the  ordinary 
signs  of  aucesthesia,  but  he  must  have  learned  to  distinguish 
shades  of  lightness  and  depth,  which  are  of  little  con- 
sequence in  anaesthesia  by  other  agents,  i.e.,  ether,  chloro- 
form, etc.  In  the  administration  of  gas  oxj^gen  the 
personal  equation  is  without  doubt  the  most  important 
element. 

Ana?sthesia  by  nitrous  oxide  and  oxygen  is  character- 
ized by  muscular  rigidity  of  varying  intensity.  This 
rigidity  is  sometimes  present  in  a  complete  and  otherwise 
entirely  satisfactory  anaesthesia. 

Some  patients  become  very  easily  relaxed,  others  re- 
main rigid  no  matter  how  much  the  anaesthetic  is  pushed. 
In  this  connection  one  should  always  remember  that  relaxa- 
tion will  never  occur  in  the  presence  of  cyanosis.  If  the 
desired  result  cannot  be  obtained  without  the  presence  of 
asphyxia  then  ether  should  be  employed. 


NITROUS  OXIDE  OXYGEN  ANAESTHESIA  217 

When  nitrous  oxide  and  oxygen  is  the  anaesthetic  em- 
ployed the  a(hninistrator  must  have  the  co-operation  of 
the  surgeon.  The  surgeon  must  unbend  and  tlie  ana'sthe- 
tist  must  rise  to  the  occasion.  Gas  oxygen  anaesthesia 
given  by  the  sub- junior  for  the  chief  is  very  likely  to 
be  a  failure. 

With  gas  oxygen  anasthesia,  more  than  with  any  other 
agent,  we  wish  to  go  on  record  as  insisting  that  the  patient 
he  the  criterion  of  the  mixture  delivered.  An  anaesthetist, 
who  will  not  give  additional  oxygen  because  his  apparatus 
indicates  a  certain  theoretical  percentage,  even  though 
the  patient  be  dying  of  asphyxia,  certainly  has  no  business 
to  use  this  method.  The  author  has  seen  a  patient  posi- 
tively gray,  crying  out  for  oxygen  by  every  possible  sign, 
ignored  by  the  anesthetist,  who  was  sure  that  all  was  safe 
because  his  apparatus  showed  such  and  such  a  percentage 
mixture  in  process  of  delivery.  If  preconceived  and  pre- 
arranged mixtures  do  not  fit  the  needs  of  the  patient,  these 
must  be  thrown  to  the  winds  and  suitable  percentages 
employed. 

The  administration  of  gas  and  oxygen  is  gradually 
beginning  to  find  its  place.  It  has  thrown  off  many  of  its 
early  excrescences,  such  as  positive  pressure,  heated  vapors, 
and  the  like.  Numberless  apparatus  of  beautiful  design 
and  workmanship  have  died  of  complexity.  Unskilful 
enthusiasts  have  fortunately  lost  interest,  and  are  no 
longer  forcing  the  method  where  it  is  counterindicated. 
Unfortunately,  however,  their  blunders  live  on  in  the  minds 
of  the  surgeons  whom  they  chanced  to  assist.  These  ex- 
periences naturally  give  rise  to  prejudice  against  a  method 
which  is  invaluable  in  its  place.  The  administration  of  gas 
oxygen  anasthesia  is  intimately  bound  up  with  the  present 


218  ANESTHESIA 

day  theories  regarding  the  physiology  of  CO2  gas.  Since 
this  consideration  is  deserving  of  more  space  than  can  be 
devoted  in  this  section,  the  reader  is  referred  to  the  chapter 
on  "  Carbon  Dioxide  and  Rebreathing,"  page  296. 

As  the  symptoms  and  signs  of  gas  oxygen  anesthe- 
sia change  with  great  rapidity,  we  must  make  use  of  an 
apparatus  which  will  be  sufficiently  elastic  to  meet  these 
changes  of  state  as  they  appear.  We  must  be  able  to 
produce  N2O  effects  or  oxygen  effects  without  delay. 
This  result  may  be  obtained  by  introducing  both  the  gas  and 
the  oxygen  proximal  to  the  rebreathing  bag,  not  at  the 
bottom  or  distal  end  of  the  bag  as  is  the  usual  custom. 
This  principle  may  be  applied  to  any  apparatus.  Fig.  72 
shows  its  application  in  the  apparatus  used  by  the  author. 
If  this  method  be  employed,  should  the  patient  show  signs 
of  'coming  out,'  he  can  be  given  pure  nitrous  oxide  at 
once.  It  is  not  necessary  to  wait  for  the  contents  of  the 
rebreathing  bag  to  discharge  itself  before  the  effects  of 
the  N2O  are  felt.  The  same  condition  applies  to  the  use 
of  oxygen,  immediate  effects  being  secured  upon  turning 
on  the  gas. 

The  preliminary  use  of  morphine  and  atropine  is  abso- 
lutely necessary  for  smooth  gas  oxygen  anaesthesia. 

The  Signs  of  Nitrous  Oxide  Oxygen  Anesthesia 

Color. — The  most  important  sign  which  we  have  in 
gas  oxygen  anaesthesia  is  the  color.  As  with  ether,  duski- 
ness is  more  liable  to  occur  in  the  full-blooded,  muscular 
individual.  With  ether,  however,  duskiness  or  cyanosis 
is  usually  directly  dependent  upon  obstruction  to  the  res- 
piration, while  with  gas  oxygen  the  condition  frequently 


NITROUS  OXIDE  OXYGEN  ANESTHESIA  219 

depends  upon  the  mixture  of  the  gases  offered  to  the 
patient.  As  lias  been  pointed  out  under  general  considera- 
tions, complete  antesthesia  and  a  normal  color  are  obtained 
only  when  oxygen  is  employed.  Those  who  are  unfamiliar 
with  gas  oxygen  anaesthesia,  but  who  have  had  some  ex- 
perience with  N2O  alone  are  very  likely  to  purposely 
avoid  a  pink  color  fearing  that  the  patient  will  "  come 
out."  A  good  color  is  especially  desirable  where  the  best 
relaxation  is  required.  By  pushing  the  X^O  to  a  degree 
of  asphyxia,  we  not  only  do  not  overcome  the  rigidity  but 
we  superimpose  the  rigidity  which  accompanies  imperfect 
oxygenation. 

For  the  above  reasons  gas  oxygen  anaesthesia  per  se 
cannot  be  satisfactorily  administered  in  the  dark,  i.e.,  for 
nose  and  throat  and  for  cystoscopic  examinations.  To 
employ  this  method  under  these  conditions  is  to  court  fail- 
ure and  to  risk  the  life  of  the  patient. 

The  difficulty  of  properly  judging  the  color  in  negroes 
excludes  them  from  this  method  unless  special  indications 
are  present. 

The  color  of  the  patient  is  the  only  reliable  index  of 
the  amount  of  oxygen  which  should  be  delivered.  Any 
apparatus  which  does  not  accept  the  color  of  the  jjatient 
as  the  criterion  for  the  increase  or  the  diminution  of  the 
oxygen  supply  is  pernicious.  Where  such  apparatus  is 
employed  as  will  deliver  definite  mixtures  of  N-O  and 
oxygen  there  must  be  some  provision  made  for  the  imme- 
diate and  copious  admission  of  oxygen,  should  such  treat- 
ment be  found  necessary.  The  margin  of  safety  in  gas 
oxygen  anaesthesia  is  narrow,  much  more  narrow  than 
with  ether  and  we  cannot  force  our  methods  as  we  may 
occasionallv  do  with  the  latter. 


220  ANESTHESIA 

Respiration. — Next  to  the  color  sign  the  respiration 
is  the  most  important  symptom  of  gas  oxygen  anaesthesia. 
During  the  early  part  of  induction  the  respirations  are 
very  likely  to  be  more  rapid  and  deeper  than  normal.  In 
some  athletic  patients  this  may  amount  to  a  hypercapnia, 
which  will  seriously  disturb  our  induction.  If  the  color  is 
held  under  good  control  by  sufficient  oxygen,  however,  the 
breathing  soon  becomes  less  rapid  and  more  shallow.  A 
soft  snore  is  one  of  the  first  signs  of  good  ancesthesia.  If 
this  continues,  and  the  respirations  remain  regular  and 
somewhat  deeper  than  normal,  the  preparation  of  the  field 
of  operation  may  be  begun.  A  patient  whose  respirations 
are  shallow  and  slow  is  not  anaesthetized.  Air  has  prob- 
ably leaked  in  under  the  face  piece  and  manipulations 
begun  at  this  time  will  result  in  trouble.  One  has  to  "  feel 
out  "  each  patient  and  determine  the  approximate  amount 
of  oxygen  which  is  required.  The  reaction  of  the  respira- 
tion to  vigorous  "  scrubbing  up  "  is  valuable.  If  the 
rhythm  is  not  affected  the  incision  may  safely  be  made. 
During  the  mainte7icmce  of  the  anaesthetic  the  rhythm 
and  the  depth  of  the  respirations,  in  conjunction  with  the 
color,  form  our  chief  guide  as  to  the  condition  of  the 
patient.  The  most  imj^ortant  factor  in  the  control  of  the 
respiration  is  the  extent  to  which  rebreathing  is  permitted. 
The  stimulating  effect  of  the  CO2  thus  obtained  is  more 
active  than  where  ether  is  the  anaesthetic  (see  page  303). 

Relaxation. — With  gas  oxygen  anaesthesia  there  is 
no  true  relaxation  (see  page  57).  We  expect  and 
usually  find  more  or  less  rigidity.  The  muscle  tone  is 
prone  to  persist.  The  impossibility  of  obtaining  true  mus- 
cular relaxation  when  gas  oxygen  is  the  anfesthetic  is  being 
borne  in  upon  us  by  repeated  failures  where  these  gases 


NITROUS  OXIDE  OXYGEN  ANESTHESIA  221 

used  alone  are  employed  for  abdominal  work.  The  proper 
understanding  of  this  rigidity  by  the  surgeon  and  the 
amesthetist  will  produce  far  more  satisfactory  results. 
The  surgeon  nmst  realize  the  conditions  imder  which  he 
is  obliged  to  work.  The  anaesthetist  must  realize  the 
effects  which  he  can  produce,  know  when  he  has  reached 
the  limit  and  not  persist  in  attempting  the  impossible  at 
the  expense  of  the  patient  and  the  surgeon. 

If  absolute  relaxation  is  not  essential,  however,  for 
the  work  in  hand,  gas  oxygen  anaesthesia  is  tlie  ideal 
anaesthetic. 

When  induction  has  been  completely  brought  about 
the  lid  reflex  will  be  sluggish.  Slight  muscular  move- 
ments of  the  limbs  occasionally  occur  but  as  a  rule  the 
patient  is  absolutely  quiet.  Masseteric  relaxation  is  never 
complete  where  the  gases  are  employed  without  ether. 

The  Pulse. — A  slow  pulse,  fifty  or  less,  under  gas 
oxygen  anesthesia  is  a  danger  sign.  Rebreathing  should 
be  diminished  and  the  general  condition  of  the  patient  care- 
fully watched. 

The  Eye  Signs. — When  anaesthesia  is  fully  induced 
the  globes  are  fixed,  looking  forward,  downward  or  upward. 
(This  sign  is  a  guarantee  that  consciousness  is  lost.) 

During  the  stage  of  maintenance  the  light  reflex  is 
active;  the  pupils  are  contracted;  the  conjunctivo  palpe- 
bral reflex  is  active;  the  corneal  reflex  is  always  snappy. 

The  Point  of  View  of  the  Surgeon,  Anaesthetist  and 
Patient  in  Regard  to  Gas  Oxygen  Anaesthesia 

The  inconvenience  of  the  surgeon  adapting  himself  to 
an  anaesthesia  which  does  not  yield  complete  muscular 
relaxation  is  certainly  a  serious  objection.    A  man  who  has 


222  ANESTHESIA 

been  accustomed  for  years  to  the  freedom  of  manipulation 
which  ether  affords  when  properly  administered  often 
finds  it  not  only  difficult  but  im^^ractical  to  work  with  this 
anesthetic.  His  attitude  will  be  largely  governed  by  his 
estimation  of  the  value  of  gas  oxygen  in  the  recovery  and 
convalescence  of  the  patient. 

The  Ax.esthetist. — Gas  oxygen  anaesthesia  is  by  far 
the  most  difficult  of  all  anaesthetics  to  administer.  From 
the  aspect  of  mere  labor  the  method  is  unpopular  for  those 
who  simply  give  "  dope;"  but  for  the  man  wno  can  catch 
the  spirit  of  the  work,  for  the  man  who  is  interested  in 
the  Art  of  Anccsthesia  the  method  is  fascinating.  The 
recovery  in  a  case  of  gas  oxygen  ansesthesia  properly 
administered  is  a  triumph  in  itself. 

The  Patient. — From  the  point  of  view  of  the  patient 
the  method  is  the  most  satisfactory  yet  devised.  After- 
symptoms  are  conspicuous  by  their  absence.  The  patient 
is  scarcely  ever  sick  although  retching  before  consciousness 
returns  is  frequently  seen.  The  disadvantage  of  a  rapid 
return  of  consciousness  is  so  far  outbalanced  by  the  bene- 
fits as  to  be  of  little  consequence.  To  see  a  patient  pass 
in  two  minutes  from  a  stage  of  deep  anaesthesia,  in  which 
he  has  been  maintained  for  an  hour  or  more,  to  complete 
consciousness  is  the  marvel  of  present-day  anaesthesia. 
And  by  consciousness  w^e  mean  complete  orientation ;  a  con- 
sciousness which  is  capable  of  calmly  surveying  immediate 
past  experiences  and  which  fully  understands  existing 
conditions. 


CHAPTER  IX 
NITROUS  OXIDE  OXYGEN  ETHER  ANAESTHESIA 

Owing  to  the  objectionable  muscular  tone  and  rigidit}^ 
which  exist  when  gas  oxygen  is  given  per  se,  even  though 
preceded  by  morphine  and  atropine,  etlier  has  been  added 
to  a  greater  or  less  degree. 

The  addition  of  small  amounts  of  ether  greatly  in- 
creases the  efficiency  of  the  control.  Owing  to  the  deep 
and  rapid  respirations  wliich  obtain  in  gas  oxygen  anaes- 
thesia it  is  quite  easy  to  quickly  introduce  ether  into  the 
circulation.  For  the  same  reason  ether  once  introduced 
and  then  stopped  may  be  rapidly  expelled  by  rebreathing 
gas  and  oxygen. 

When  ether  is  used  in  sufficient  quantity  at  the  proper 
time,  we  believe  that  the  resulting  anaesthesia  is  the  best 
all-round  method  thus  far  devised.  Where  relaxation  is 
necessary  for  the  surgeon,  we  believe  that  ether  should  be 
freely  used. 

The  author's  method  of  choice  in  all  adults  where  the 
operation  does  not  involve  the  respiratory  tract  is  as 
follows : 

A  preliminary  hypodermic  of  morphine  1/6  and  atro- 
pine 1/150  is  given  half  an  hour  before  the  time  set  for 
operation.  Anasthesia  is  induced  with  gas  alone  or  with 
gas  oxygen.  If  the  operation  be  intra-abdominal,  a  com- 
plete ether  anaesthesia  by  the  closed  method  is  then  ob- 
tained. The  best  relaxation  is  thus  secured  for  explora- 
tion. If  intestinal  work  is  now  to  be  done  (the  visceral 
peritoneum  being  insensitive)  the  ether  is  stopped  and  gas 
oxygen  is  used.     If  the  gall-bladder  be  manipulated  and 

223 


224  ANESTHESIA 

reflex  rigidity  ensue,  ether  may  again  be  resorted  to.  At 
the  beginning  of  the  stage  of  recovery  (see  page  74),  or 
when  the  peritoneum  is  closed,  the  ether  is  completely  shut 
off  and  gas  oxygen  alone  is  used  with  very  little  rebreath- 
ing.  By  the  time  the  operation  is  concluded  (15-20  min- 
utes) so  much  of  the  ether  has  been  thrown  off  that  there 
is  scarcely  any  ether  on  the  patient's  breath.  The  return 
of  consciousness  is  somewhat  more  delayed  than  with  gas 
oxygen  per  se.  The  after-symptoms  are  conspicuous  by 
their  absence;  persistent  nausea  and  vomiting  being  very 
uncommon.  (This  method  has  frequently  been  employed 
by  W.  B.  Gatch  and  others.) 

Such  a  type  of  anaesthesia  is  ideal  for  the  surgeon,  more 
satisfactory  for  the  anfesthetist  and  from  the  point  of  view 
of  the  patient  approaches  the  ideal  obtained  by  the  use  of 
gas  oxygen  alone. 

Where  ether  is  freely  used  it  is  not  so  essential  to  pre- 
cede the  administration  by  morphine  and  atropine.  The 
effects  are  generally  better  when  this  treatment  is  followed, 
however,  as  the  pain  of  the  wound  is  minimized  after  the 
recovery  of  the  patient,  who  often  falls  into  a  light  sleep 
shortly  after  returning  to  bed. 

By  the  employment  of  this  method  we  believe  that  we 
obtain  the  best  all-round  results:  rapid  induction,  com- 
plete relaxation,  ready  control,  minimum  after-effects,  all 
with  the  greatest  pathological  safety  to  the  patient. 

The  Administration  of  Gas  Oxygen  Ether 
Anesthesia 

Two  methods  of  administration  are  recognized : 

1.  The  method  of  intermittent  flow  with  rebreathing. 

2.  The  method  of  constant  flow  (a)  with  rebreathing; 
(h)  without  rebreathing. 


NITROLS  OXIDE  OXYGEN  ETHER  ANAESTHESIA  225 

The  Administration  of  Gas  Oxygen  Ether  Anaes- 
thesia BY  THE  Method  of  Intermittent  Feow  with 
Rebreathing 

This  method  is  the  simpler  of  the  two,  consumes  about 
half  the  amount  of  gases  but  is  thought  by  some  to  give  a 
somewhat  more  uneven  level  of  maintenance.    This  method 
is  the  one  introduced  by  W.  Gatch,  of  Johns  Hopkins 
Hospital,  Baltimore.     It  requires  the  closest  attention  to 
detail  as  does,  in  fact,  any  method  of  gas  oxygen  amesthesia. 
The  author  has  enjoyed  such  success  with  this  method  that 
he  is  reluctant  to  replace  it  by  others. 
For  apparatus  used  see  Fig.  72. 
The  administration  is  conducted  as  follows : 
The  use  of  a  preliminary  hypodermic  of  morphine  gr. 
1/4  and  atropine  gr.  1/150,  where  not  distinctly  contraindi- 
cated,   administered   half   an  hour  before   anesthesia,   is 
absolutelv  essential  to  the  success  of  nitrous  oxide  oxysfen 
anaesthesia. 

Hyoscine  gr.  1/100  and  morphine  gr.  1/4  one  hour 
before  anaesthesia  are  an  ideal  medication  in  large  muscular 
people.  The  disadvantages  of  hyoscine  are  largely  coun- 
teracted by  the  emjjloyment  of  rebreathing. 

It  is  difficult  to  overestimate  the  value  of  suggestion. 
A  few  words  of  sympathetic  reassurance  will  do  much 
towards  improving  the  anaesthesia. 

Experience  only  will  give  familiarity  with  the  apj^ara- 
tus  and  the  best  results.  If  the  nitrous  oxide  and  oxygen 
cannot  be  made  to  work  in  a  particular  case,  ether  and 
oxygen  may  be  given  by  the  closed  method. 

Before  starting  the  anaesthesia,  take  a  piece  of  brass 
wire  gauze  2  inches  by  1.5  inches  of  a  size  known  as  100  to 
the  inch.    Make  a  roll  of  this  and  place  it  under  the  ether 

15 


226  ANESTHESIA 

cup.  Assemble  the  apparatus  and  by  a  little  twist  open 
the  dome  top.  This  cuts  out  the  gas  and  ether  chamber. 
Fill  the  bag  slowly,  by  little  spurts,  with  nitrous  oxide. 
(Rapid  filling  causes  frozen  valves,  cold  gas  and  noise.) 
See  that  the  needle  valve  is  closed.  Fill  the  ether  cup. 
Place  an  ether  can  cork,  with  a  string  tied  to  it,  on  its 
side  between  the  right  front  molars.  Apply  face  piece, 
being  particularly  careful  of  the  coaptation  over  the  bridge 
of  the  nose  and  under  cheek.  Turn  the  head  to  the  right 
side  and  instruct  the  patient  to  breathe  naturally  through 
the  mouth.  He  is  now  getting  only  air.  Push  down  air 
shut-off,  and  fasten  by  twist.  The  patient  is  now  re- 
breathing  nitrous  oxide. 

Open  the  expiratory  valve  and  the  patient  will  begin  to 
empty  the  bag.  Allow  the  bag  to  empty  about  two-thirds, 
release  the  expiratory  valve  and  slowly  run  in  more  nitrous 
oxide  and  a  little  oxygen.  The  amount  of  oxygen  can 
only  be  learned  by  experience.  (Freedom  from  cj^anosis 
with  a  light  pink  color.)  The  breathing  will  become  deep 
and  full.  Presently  a  snoring  will  be  heard.  This  is  a 
sign  of  sufficient  amesthesia  to  start  scrubbing  up.  In 
shallow  breathers  this  may  be  delayed  for  some  time.  If 
the  snore  is  absent  after  four  or  five  minutes,  cautiously 
drop  in  a  little  ether.  If  the  respirations  continue  un- 
changed, there  are  good  evidences  that  the  patient  is  well 
ansesthetized.  The  conjunctivo-corneal  reflexes  are  so  ac- 
tive that  in  the  early  stages  particularly  they  are  of  little 
assistance. 

It  is  always  well  to  test  out  the  patient's  reaction  to 
ether,  as  later,  particularly  in  abdominal  operations,  ether 
becomes  an  absolute  necessity  for  the  relaxation  of  the 
abdominal  muscles. 


NITROUS  OXIDE  OXYGEN  ETHER  AN.ESTHESL\  227 

The  reaction  of  the  respiration  and  any  sHght  move- 
ment during  the  scrubbing  up  will  give  one  a  good  idea  of 
the  depth  of  the  anaesthesia.  Just  before  the  incision  is 
made,  particularly  in  abdominal  cases,  increase  the  per- 
centage of  nitrous  oxide  by  half  emptying  the  bag  and 
refilling  with  pure  nitrous  oxide.  At  the  same  time  have 
the  patient  under  ether  control.  That  is,  have  him  where 
he  will  accept  ether  without  spasm.  If  the  res2)iration  is 
not  affected  by  the  incision,  if  there  is  no  slight  movement 
of  the  extremities,  and  the  surgeon  does  not  complain  of 
abdominal  rigidity,  stop  the  ether  and  carry  the  patient 
along  on  a  faint  pink  color. 

The  respiration  must  be  kept  free.  The  use  of  the 
ether  can  cork  now  becomes  apparent.  In  the  case  of 
obstruction,  the  teeth  are  sufficiently  separated  to  admit  of 
the  easy  introduction  of  the  mouth  gag  in  the  upper  or 
left  side  of  the  mouth.  The  throat  tube  may  then  be 
inserted  without  difficulty.  This  will  be  found  of  greatest 
assistance  where  indicated. 

Should  necessity  arise,  particularly  in  the  early  stages 
for  considerable  ether,  one  need  not  be  alarmed,  for  this 
ether  can  be  disposed  of  by  stopj^ing  its  administra- 
tion early,  using  only  gas  and  oxygen,  and  frequently 
emptying  the  bag.  During  the  course  of  an  even  an<esthe- 
sia,  ^vhen  adding  nitrous  oxide  and  oxygen,  it  has  been 
found  more  satisfactory  not  to  empty  the  bag  completely, 
but  about  half  the  bag  at  the  time,  this  being  repeated 
every  two  or  three  minutes.  This  does  not  make  such  a 
radical  change  in  the  mixture  and  never  leaves  the  bag 
without  carbon  dioxide,  the  respiratory  stimulant. 

Trouble. — If  one  is  in  trouble  and  cannot  determine 
just  where  the  patient  is,  always  give  him  the  benefit  of  the 


228  ANAESTHESIA 

doubt,  and  stop  the  anaesthetic  by  opening  the  air  vent. 
The  contents  of  the  bag  are  saved  and  ready  for  immediate 
reapplication.  A  few  breaths  of  fresh  air  will  change  the 
picture  completely  and  assure  safety. 

Respiration  very  deep  and  slow — usually  too  much 
rebreathing — empty  the  bag  completely  and  refill. 

Spasm  of  the  respiration — stop  ether  completely, 
empty  bag  and  give  either  air  or  oxygen,  with  a  small  per- 
centage of  nitrous  oxide. 

The  mouth  tube,  if  introduced  under  nitrous  oxide  and 
oxygen  anaesthesia  alone,  is  likely  to  cause  irritation  lead- 
ing to  respiratory  spasm  and  possibly  vomiting.  Precede 
introduction  by  a  little  ether. 

Shallow  breathing  under  hyoscine — increase  carbon 
dioxide  by  rebreathing. 

Respirations  deep  and  slow,  growing  shallower  and 
remaining  slow  (o-lO)  a  minute — suspect  Cheyne  Stokes 
respiration,  stop  the  anaesthetic  and  look  for  trouble. 

Rapid  respiration,  corneal  reflex  gone — probably  too 
much  ether. 

Abdominal  rigidity  in  the  jDresence  of  deep  ether — res- 
piration obstructed  or  faulty  position  on  the  table. 

Movement — profound  gas  anaesthesia,  jactitation,  or 
anaesthesia  incomplete. 

Pulse  slower  than  normal — too  much  rebreathing, 
danger  signal. 

Blue — too  large  percentage  of  gas,  respiratory  obstruc- 
tion, or  both. 

Bright-red — too  much  oxygen,  valves  in  oxygen  cylin- 
der leaking,  not  shut  off,  or  air  leaking  in  about  the  face 
piece. 

Don't  expect  a  bright  color  in  sallow  people. 

Don't  give  gas  and  oxygen  to  negroes. 


NITROUS  OXIDE  OXYGEN  ETHER  ANESTHESIA  229 

Sweating :  forehead  warm — too  much  rebreathing. 

Sweating:  forehead  cold — shock. 

Increased  hemorrhage  of  dark  blood — respiratory  ob- 
struction alone  or  combined  with  too  much  rebreathing 
and  nitrous  oxide. 

Swallowing — an  indication  of  shallow  anaesthesia,  im- 
mediately precedes  vomiting.  Increase  anaesthesia  by  gas 
or  ether. 

Vomiting — stop  anaesthesia,  allow  reflexes  to  return 
and  thereby  provide  against  the  aspiration  of  vomitus. 

Immediately  following  an  attack  of  vomiting  the  pa- 
tient will  return  quickly  and  smoothly  to  the  anaesthetic 
state. 

Retching — increase  gas  and  ether. 

Sphincter  dilation  and  gall-bladder  work  may  show  it- 
self reflexly  even  in  the  presence  of  a  sufficiently  deep 
anaesthesia. 

Vomiting  may  be  purely  morphine  in  origin. 

Vomiting  during  recovery  seems  to  depend  upon  the 
use  of  morphine,  the  preparation  of  the  patient,  the  nature 
of  the  operation,  the  amount  of  ether  used,  and  the  degree 
to  which  rebreathing  is  carried. 

Hysteria — use  suggestion,  and  morphine  combined 
with  hyoscine. 

Hiccough — rare  in  nitrous  oxide  oxygen  anaesthesia; 
increase  gas  and  rebreathing. 

Headache  during  recovery — uneven  anaesthesia  with 
too  much  rebreathing. 

Corneal  reflex  gone — usually  deep  anaesthesia. 

Nystagmus  and  active  corneal-lid  reflex — shallow 
anaesthesia. 

Hearing  is  acute  during  the  early  stages  of  nitrous 
oxide  oxygen  anaesthesia — be  quiet. 


S30 


ANAESTHESIA 


The  Administration  of  Gas  Oxygen  Ether  Anes- 
thesia BY  THE  Method  of  Constant  Floay  with 
Rebreathing 

A  constant  flow  of  gases  with  limited  rebreathing  is 
employed  by  A.  H.  Miller,  of  Providence,  whose  appara- 
tus (Fig.  105),  represents  a  popular  type. 

This  apparatus  is  very  ingenious,  and  simple  in  the 
work  which  it  is  expected  to  perform.  The  control  is 
somewhat  more  ready  and  its  employment  does  not  require 


Fig.    104. — Face-piece  and  controlling  valves 


Fig.  105. — Face-piece,  controlling  valves, 
reducing  valves  and  gas  cvlinders.  (Courtesy 
Dr.  Miller.) 


so  much  mechanical  sense  on  the  part  of  the  operator,  as 
does  the  use  of  the  intermittent  flow. 

The  Nitrous  Oxide  Oxygen  Apparatus  devised  by  Dr. 
Albert  H.  Miller  provides  for  a  definite  flow  of  nitrous 
oxide  and  of  oxygen,  each  measured  in  litres  per  minute, 
to  which  may  be  added  a  definite  flow  of  vaporized  ether, 
measured  in  c.c.  per  minute. 

Two  reducing  valves,  one  for  nitrous  oxide,  and  one 
for  oxygen,  are  provided  (Fig.  105) . 

Each  reducing  valve  is  mounted  on  a  double  yoke. 
Two  cylinders  of  each  gas,  clamped  into  their  yokes,  set 
on  the  floor,  not  requiring  any  other  support.  The  reduc- 
ing valves  provide  a  supply  of  nitrous  oxide  and  of  oxygen 


NITROUS  OXIDE  OXYGEN  ETHER  ANAESTHESIA  231 

at  a  constant  pressure  of  10  pounds  to  the  square  inch. 
The  reducino-  valves  are  connected  with  the  controUino" 
valves  by  rubber  tubing. 

A  frame,  which  supports  the  controlling  valves  and 
indicators,  is  j^rovided  with  a  clamp  which  serves  to  attach 
this  part  of  the  ajDparatus  to  a  table  or  chair,  doing  away 
with  the  need  for  a  stand  (Fig.  104).  On  the  frame  are 
mounted  three  needle  valves,  two  wash  bottles,  and  a  vapor- 
izer of  special  construction.  Oxygen  passes  through  the 
valve  and  wash  bottle  on  the  left,  and  nitrous  oxide 
through  the  valve  and  bottle  on  the  right.  The  wash 
bottles  serve  as  indicators  of  the  flow  of  nitrous  oxide  and 


Fig.   106. — Face-piece,  Miller  apparatus.     (Courtesy  Dr.  Miller.) 

oxygen  and  also  moisten  the  gases.  Dials  attached  to  the 
stems  of  the  needle  valves  are  calibered  in  litres  per  min- 
ute of  flow  of  nitrous  oxide  and  of  oxygen.  The  middle 
valve  transmits  a  stream  of  nitrous  oxide  to  a  vaporizer 
which  provides  a  constant  percentage  of  ether  vapor,  varied 
by  changing  the  rate  of  flow  of  the  gas.  One  litre  of 
gas  vaporizes  in  this  way  five  c.c.  of  ether  per  minute. 
This  unit  of  the  apparatus  is  connected  with  the  inhaler  by 
rubber  tubing.  The  mixture  of  gases  takes  place  close  to 
the  face  piece. 

The  inhaler  has  a  face  piece  of  celluloid,  with  an  in- 
flatable rubber  cushion  or  a  cuff   (Fig.  106).     The  air 


232 


ANESTHESIA 


valve  on  the  inhaler  is  open  when  the  gas  is  shut  off,  and 
vice  versa.  Consequently  the  face  piece  may  be  adjusted 
to  the  face,  so  that  the  patient  becomes  accustomed  to 
breathing  through  it  before  the  ana?sthetic  is  introduced. 


Fig.  107— Miller  apparatus.    (Courtesy  Dr.  Miller.) 

The  expiratory  valve  is  mounted  on  the  inhaler  in  plain 
sight  and  is  controlled  by  a  spring  of  adjustable  tension. 
The  supply  bag,  which  serves  also  as  the  rebreathing  bag, 
is  mounted  on  the  face  piece.  The  inhaler  can  be  quickly 
separated  into  parts  which  may  be  sterilized  in  boiling 
water,  dried  inside  and  out,  and  readily  reassembled.  The 
wide  mouth  of  the  supply  bag  allows  it  to  be  turned  inside 
out  and  dried.     There  are  no  concealed  valves. 

The  first  part  of  each  expiration  passes  into  the  supply 


NITROUS  OXIDE  OXYGEN  ETHER  ANAESTHESIA  233 

bag  and  is  rebreathed.  The  latter  part  escapes  through 
the  expiratory  valve.  The  proportion  of  rebreathing  varies 
inversely  as  the  rate  of  flow  of  the  mixture.  This  propor- 
tion can  be  closely  estimated  by  noting  the  point  in  expira- 
tion at  which  the  expiratory  valve  opens.  Only  enough 
tension  on  the  expiratory  valve  is  maintained  to  insure  the 
filling  of  the  supply  bag  before  the  valve  opens. 

This  apparatus  may  be  packed  in  a  24-inch  suit  case 
for  transportation.  It  may  be  permanently  attached  to  a 
table  for  hospital  use  (Fig.  107) . 

Administration  of  Gas  Oxygen  Anaesthesia  by  the 
Method  of  Constant  Flow  Without  Rebreathing 

This  method  is  quite  different  from  those  methods 
which  employ  rebreathing.  By  this  method  an  attempt 
has  been  made  to  administer  XoO  and  O  on  a  basis  of  vapor 
tension  reducing  the  matter  to  terms  of  ether  by  the  per- 
centage method  (see  page  64).  Dr.  K.  Connell  has  ar- 
ranged the  chart  shown  in  Fig.  108,  in  which  the  effect 
of  different  percentages  of  X^O  and  O  vapor  are  shown. 
Theoretically  the  method  is  ideal.  Its  limited  employ- 
ment thus  far,  however,  compels  us  to  reserve  our  opinion 
as  to  its  practicability.  In  a  general  way  w^e  feel  the  neces- 
sity of  being  very  near  the  patient  when  w^e  administer 
gas  and  oxygen.  Any  method  which  tends  to  release  us 
from  this  responsibility  is  likely  to  result  in  sudden  disturb- 
ance, either  of  lightness  or  depth.  Fig.  109  shows  the 
regulator  em^^loyed  by  Dr.  Connell. 

From  a  point  of  view  of  expense  of  administration  the 
method  of  intermittent  use  is  the  least  expensive,  and 
the  percentage  method  with  the  constant  flow  the  most 
expensive. 


234 


ANAESTHESIA 


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NITROUS  OXIDE  OXYGEN  ETHER  ANESTHESIA  235 


The  intermittent  flow  is  exemplified  by  the  Gatch  ap- 
paratus. In  the  appended  chart  sliowing  tlie  detailed 
administration  of  one  hundred  cases  this  apparatus  was 


I 


Fia.  109. — Connell  nitrous  oxide,  oxygen,  ether  flow  control.  A,  nitrous  oxide  instanta- 
neous gas-flow  gauge  (piston  type) ;  B,  oxygen  gauge  (piston  type) ;  C,  parachute  gauge,  com- 
bined gases;  D,  ether  tank;  E,  ether  dropper;  F,  gas-control  cocks;  G,  outlet.  (Courtesy  Dr. 
K.  Connell,  Appleton  Co.,  Johnson's  Surgery.) 

employed.  The  scope  of  the  method,  the  time  of  admin- 
istration, and  the  amount  of  gas  and  O  used  are  here  clearly- 
shown. 


236  ANESTHESIA 

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NITROUS  OXIDE  OXYGEN  ETHER  ANESTHESIA  237 


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238  ANESTHESIA 


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NITROUS  OXIDE  OXYGEN  ETHER  ANAESTHESIA    239 


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240  ANESTHESIA 


SUMMARY  OF  CHART. 

Youngest  3,  oldest  70;  76  per  cent,  females. 
Morphine  and  atropine  *in  63  per  cent. 
Total  time  of  administration  103  hours. 

Nitrous  oxide  used,  3470  gals. ;  O  used  768  gals. 

Operation.  Results. 

1  Joint  examination Failure. 

2  Joint  examination. Complete  success. 

3  Laparotomy Failure. 

4  Hernia Failure. 

5  Suturing  lacerated  lip Satisfactory. 

6  Appendectomy Failure. 

7  Incision,  T.B.  abscess  of  thigh Success. 

8  Secondary  appendectomy Complete  success. 

9  Hysterectomy Failure. 

10  Femoral  hernia Failure. 

11  Cauterization  of  cancerous  cervix Complete  success. 

12  Appendectomy Satisfactory. 

13  Appendectomy Success. 

14  Sebaceous  cyst  of  neck Satisfactory. 

15  Glands  of  neck " Satisfactory. 

16  Left  nephropexy,  salpingo  ovariectomy.      .    .  Success. 

17  Appendectomy Satisfactory. 

18  Needle  in  hand Satisfactory. 

19  Foreign  body  in  ear Satisfactory. 

20  Pus  appendix Complete  success. 

21  Fracture  of  humerus Failure. 

22  Glands  of  neck Success. 

23  Int.  obstruction,  pyo  salpinx.    .......  Complete  success. 

24  Hysterectomy Satisfactory. 

25  Trephine  of  fractured  skull Satisfactory. 

26  Needle  in  thumb Satisfactory. 

27  Exploratory  laparotomy Satisfactory. 

28  Fracture  of  tibia,  set Complete  success. 

29  Curettage,  trachelorrhaphy  laparotomy.     .    .  Complete  success. 

30  Hysterectomy Complete  success. 

31  Curettage,  trachelorrhaphy,  perineum  appen- 

dectomy and  ant.  suspension Complete  success. 

32  Removal  of  cyst  of  broad  ligament Complete  success. 

33  Removal  of  axillary  glands Complete  success. 

34  Needle  in  foot Complete  success. 

35  High  forceps.   .    .    .    ; Complete  success. 


NITROUS  OXIDE  OXYGEN  ETHER  ANAESTHESIA  241 

Operation.  Results. 

36  Modified  Gilliam  operation Complete  success. 

37  Laparotomy Complete  success. 

38  Appendicitis Failure. 

39  Appendectomy,  double  salpingo  ovariectomy 

and  curettage Complete  success. 

40  Curettage .  Complete  success. 

41  Curettage Satisfactory. 

42  Injured  joint Complete  success. 

43  Exploratory  laparotomy Success. 

44  Cellulitis  of  the  face Satisfactory. 

45  Cholecystostomy Complete  success. 

46  Glands  of  the  neck Satisfactory. 

47  Salpingo  ovariectomy,  appendectomy.    .    .    .  Satisfactory. 

48  Curettage Satisfactory. 

49  Posterior  colpotomy Satisfactory. 

50  Dressing.  . Complete  success. 

51  Lacerated  perineum Complete  success, 

52  Resection  of  stump Complete  success. 

53  Inguinal  hernia Complete  success. 

54  Curettage  and  trachelorrhaphy Complete  success. 

55  Perineum  and  ant.  suspension Success. 

56  Pus  appendix Satisfactory. 

57  Pus  appendix Satisfactory. 

58  Inguinal  hernia Complete  success. 

59  Appendectomy Failure. 

60  Hernia Success, 

61  Curettage Complete  success, 

62  Hernia Satisfactory, 

63  Removal  of  ovarian  cyst Complete  success. 

64  Ventral  suspension Satisfactory. 

65  Appendectomy Satisfactory. 

66  Secondary  cholecystostomy Success. 

67  Irreducible  umbilical  hernia Complete  success. 

68  Rectal  fissure.  Complete  success. 

69  Tonsils  and  adenoids Satisfactory. 

70  Appendectomy Satisfactory 

71  Laparotomy Failure. 

72  Hysterectomy.     •    ••    • Complete  success. 

73  Pyo  salpinx  and  appendicitis Complete  success. 

74  Curettage. Complete  success. 

75  Hemorrhoids Success. 

76  Pus  appendix Complete  success. 

77  Curettage  and  exploratory  laparotomy  .    .    .  Died. 

16 


242  ANAESTHESIA 

Operation.  Results. 

78  Laparotomy Complete  success. 

79  Curettage Satisfactory. 

80  Curettage Satisfactory. 

81  Intestinal  obstruction Success. 

82  Glands  of  neck Complete  success. 

83  Tonsils  and  adenoids Complete  success. 

84  Secondary  for  mastoid Complete  success. 

85  Radical  op.  for  hydrocele Complete  success. 

86  Sebaceous  cyst  of  forehead Complete  success. 

87  Appendectomy Failure. 

88  Curettage Success. 

89  Wiring  fractured  humerus Complete  success. 

90  Cauterization  of  the  vulva,  condyloma.    .    .  Satisfactory. 

91  Hysterectomy,  vaginal  and  abdominal.     .    .  Complete  success. 

92  Amputation  of  the  breast Complete  success. 

93  Laparotomy Success. 

94  Urethral  dilatation Failure. 

95  Opening  sinus  in  arm Complete  success. 

96  Posterior  colpotomy  and  abdominal  section.  Complete  success. 

97  Intestinal  obstruction Complete  success. 

98  Appendectomy Success. 

99  Appendectomy Success. 

100  Exploratory  laparotomy Success.* 

In  a  paper  read  before  the  Westchester  County  Medical  Society,  January 
16, 1912,  and  published  in  the  New  York  State  Journal  of  Medicine  for  April, 
a  series  of  one  hundred  cases  of  nitrous  oxide  oxygen  anaesthesia  were  reported. 
Case  No.  77  is  reported  to  have  died.  Space  did  not  permit  of  a  detailed 
report  of  this  case,  but  as  deaths  on  the  table  while  using  nitrous  oxide  oxygen 
as  an  anaesthetic  are  of  importance  and  interest  at  the  present  time,  this 
report  perhaps  deserves  more  than  a  passing  notice. 

It  is  an  open  question  as  to  whether  or  not  this  death  occurred  as  the 
result  of  the  use  of  nitrous  oxide  oxygen  ether  as  an  anaesthetic.  The  reader 
may  judge  for  himself  from  the  following  facts: 

Patient,  a  large,  fleshy  colored  woman,  aged  25.  She  had  been  bleeding 
almost  continuously  for  a  period  of  four  or  five  months.  Two  years  ago  her 
right  tube  and  ovary  were  removed.  Before  the  operation  a  tentative  diagno- 
sis of  uterine  fibroid  was  made.  The  enlargement  upon  the  body  of  the 
uterus  which  gave  rise  to  this  diagnosis  proved  later  to  be  occasioned  by 
adhesions  about  the  proximal  end  of  the  tube,  which  had  been  tied  oif  by  a 
heavy  silk  ligature.     No  fibroid  of  the  uterus  or  appendages  could  be  found. 

The  patient  was  reported  to  have  had  an  attack  of  syncope  shortly  before 
the  operation.     About  twenty  minutes  before  being  anaesthetized  she  received 


*  Reprinted  from  New  York  State  Medical  Journal. 


NITROUS  OXIDE  OXYGEN  ETHER  ANESTHESIA  243 

^4  gr.  morphine  and  1/150  gr.  atropine  hypodermically.'  When  she  entered 
the  operating  room  she  was  in  a  very  nervous  frame  of  mind.  The  examina- 
tion of  her  heart  had  been  negative.  The  apex  beat,  however,  was  heaving 
and  forceful.  Anaesthesia  was  induced  at  4  p.m.  The  patient  went  under 
quietly.  As  there  was  evidence  of  shallowness  in  her  anaesthetic  state  ether 
was  given  to  the  extent  of  about  one  dram.  Shortly  after  this  the  respirations 
were  obstructed  by  masseteric  spasm.  The  cervix  was  dilated  and  the  uterus 
curetted.  The  respirations  were  then  irregular  and  obstructed.  The  operator 
made  the  remark  that  the  blood  looked  dark  (the  black  skin  made  it  difficult  to 
properly  judge  the  normal  color).  The  ether  and  gas  were  stopped  and  a 
large  proportion  of  oxygen  was  given.  The  patient  was  replaced  in  the  dorsal 
position  and  the  breathing  immediately  improved.  When  the  abdominal 
incision  was  made  the  tissues  looked  extremely  anaemic.  Moderate  muscular 
relaxation  was  present.  The  pulse  was  of  good  quality  but  variable,  rapidity 
about  1^0.  The  corneal  reflex  was  active  and  the  pupils  were  contracted. 
During  the  course  of  the  operation  (which  occupied  1.17  from  the  induction 
to  the  cessation  of  the  respiration),  the  breathing  was  irregular,  slowing  to 
from  three  to  four  a  minute  and  then  increasing  in  rapidity.  While  the 
abdominal  work  was  being  done  it  was  thought  that  this  condition  was  due 
to  pulling  upon  the  viscera,  there  being  an  absence  of  signs  of  deep  anaesthesia. 
Toward  the  end  of  the  operation  the  cheeks  and  forehead  became  cold,  as 
though  the  patient  was  suffering  from  shock.  This  condition  was  not  war- 
ranted by  the  nature  of  the  operation  or  the  loss  of  blood.  The  mask  was 
removed  several  times  from  the  face  and  the  patient  rapidly  came  out.  When 
the  mask  was  replaced  a  large  proportion  of  oxygen  was  given.  Several  times 
the  corneal  reflex  was  lost,  to  reappear  again  almost  immediately.  The  breath- 
ing improved  as  the  operation  was  concluded.  When  the  patient  was  raised 
from  the  Trendelenburg  it  improved  markedly.  At  this  time  the  operator 
said :  "  She  is  pretty  rigid."  As  the  patient  had  been  behaving  badly  no 
ether  was  given  her,  but  oxygen  instead,  in  the  hope  that  the  rigidity  was  of 
an  asphyxial  nature.  While  the  old  scar  in  the  skin  was  lieing  cut  out  the 
patient  showed  the  effects  of  peripheral  stimulation  by  breathing  more  deeply 
and  more  rapidly.  The  corneal  reflex  was  active  and  the  pupils  were  con- 
tracted. Suddenly  irregular  breathing,  simulating  that  which  had  frequently 
occurred  during  the  operation,  again  made  its  appearance.  The  patient  made 
a  low  crowing  sound  as  though  about  to  come  out.  This  was  followed  by 
slow,  deep  respirations.  The  respirations  ceased.  As  this  had  occurred  several 
times  before,  it  was  not  in  itself  particularly  disturbing.  The  pulse  could 
no  longer  be  felt,  however,  the  pupils  dilated  suddenly  and  the  corneal  reflex 
completely  disappeared.  In  the  presence  of  these  signs  artificial  respiration 
was  immediately  begun,  accompanied  by  everj'  possible  form  of  stimulation. 
The  attempted  resuscitation  was  entirely  unsuccessful. 

The  following  facts  were  noted: 

The  slow  pulse  of  asphyxial  rebreathing  did  not  occur. 

Patient  was  in  a  light  anaesthetic  state  when  she  died. 


244  ANAESTHESIA 

She  showed  evidence  of  shock  some  twenty  minutes  before. 

The  color  was  difficult  to  make  out,  but  seemed  satisfactory. 

There  was  masseteric  spasm  with  ether.  This  did  not  appear  to  seriously 
hamper  the  respirations,  but  it  showed  a  tendency  to  persist  even  when  air 
and  oxygen  was  given  in  abundance. 

The  rigidity  appeared  to  be  due  to  shallow  anaesthesia,  not  to  asphyxia. 

Death  is  thought  to  have  been  due  to  cardiac  failure,  the  remote  cause 
being  previous  protracted  hemorrhages,  the  immediate  cause  being  the  strain 
thrown  upon  the  vasomotor  system  by  respiratory  obstruction  incident  to  a 
badly  accepted  anaesthetic. 

ANESTHESIA  BY  ANOCI  ASSOCIATION  OR  THE  COM- 
BINED USE  OF  LOCAL  ANESTHESIA  AND  GAS 
OXYGEN   ETHER  ANESTHESIA 

A  visitor  at  a  clinic  where  complete  anoci  association 
is  used  cannot  fail  to  catch  the  remarkable  spirit  of  co- 
operation which  pervades  the  operating  j)ersonnel.  All 
things  are  made  to  bend  to  the  welfare  of  the  patient. 
Suggestive  therapeutics  so  valuable  as  a  preliminary  treat- 
ment to  the  angesthetic  are  here  employed  to  the  fullest 
extent. 

The  harmonious  blending  of  suggestion  and  prelim- 
inary medication  before  the  induction  of  the  anaesthetic; 
gentleness  in  voice  and  touch  combined  with  an  absolutely 
essential  and  skilful  local  anaesthesia  of  the  skin  during 
the  stage  of  induction ;  the  continued  use  of  complete  nerve 
blocking  and  care  in  the  manipulation  of  the  tissues  during 
the  stage  of  maintenance,  work  together  for  a  stage  of 
recovery  which  is  ideal.  It  is  the  remarkable  ensemble 
which  produces  the  result  seen  with  so  much  pleasure. 

There  is  nothing  very  unusual  about  the  administra- 
tion of  the  gas  oxygen  per  se.  It  is  but  complementary 
to  more  important  elements.  Briefly  such  an  administra- 
tion may  be  described  as  a  skilful  and  complete  local 
anaesthesia^  well  fortified  by  preliminary  medication,  upon 


NITROUS  OXIDE  OXYGEN  ETHER  ANESTHESIA  245 

which  is  superimposed  gas  oocygen  amesthesia,  the  essen- 
tial jnirposc  of  which  is  to  destroy  consciousness. 

Place  the  gas  oxygen  anaesthesia  first,  making  the  local 
anaesthesia  and  j^reliniinary  medication  of  secondary  im- 
portance and  the  result  is  certain  failure. 

The  nitrous  oxide  and  oxygen  (we  can  scarcely  say 
the  antesthetic)  is  often  administered  hy  nurses  esjDccially 
trained  to  this  particular  type  of  work.  Since  the  anes- 
thesia does  not  proceed  to  relaxation  and  consequent  res- 
piratory obstruction  by  the  falling  back  of  the  tongue, 
little  difficulty  is  experienced  in  the  anjesthetization.  The 
chief  requirement  being  to  control  the  color.  This  is  easily 
accomplished  by  simple  and  convenient  valves  in  the 
machine  used. 

An  hour  before  o^ieration  the  patient  receives  mor- 
jDhine  grs.  li  and  scopolamine  grs.  1/200.  If  he  or  she 
be  an  epileptic  the  dose  of  morphine  is  increased  to  ^  grs., 
the  amount  of  scopolamine  remaining  unchanged. 

Cases  of  exophthalmic  goitre  are  aucesthetized  in  their 
beds  and  carefully  transported  to  the  operating  room.  All 
other  cases  are  ana?sthetized  on  the  operating  table  in  the 
operating  room.  Before  ana?sthesia  is  commenced  the  an- 
aesthetist speaks  a  few  words  to  the  patient  in  order  to 
quell  any  anxiet}'  which  may  be  present.  Most  of  the 
cases,  however,  are  well  under  the  influence  of  their  pre- 
liminary medication  by  this  time.  Nitrous  oxide  is  then 
made  to  flow  through  the  face  piece  and  down  over  the 
face  of  the  patient  before  the  mask  is  actually  applied. 
Cotton  is  placed  over  the  bridge  of  the  nose,  and  on  the 
cheeks  corresponding  to  the  point  of  contact  of  the  mask 
when  applied.  A  little  cotton  is  also  placed  about  the 
respiratory  valve  to  protect  the  anaesthetist  from  the  ex- 


246  ANAESTHESIA 

pirations  of  the  patient.  An  ordinary  hand  towel  is  placed 
under  the  nape  of  the  neck,  the  ends  lying  free.  The  time 
of  induction  varies  from  ten  to  fifteen  minutes.  The 
period  of  excitement  is  seldom  seen.  Before  consciousness 
is  lost  no  restraint  is  applied,  but  four  attendants,  an  assis- 
tant anesthetist,  an  orderly  and  two  nurses  stand  by  until 
anaesthesia  is  well  under  way.  When  consciousness  is  lost 
the  arms  are  fastened  to  the  table  by  wristlets  and  a  strap 
is  thrown  over  the  knees.  These  restraining  measures  are 
most  valuable  in  case  of  lightness  during  maintenance. 
The  free  ends  of  the  towel  lying  under  the  neck  are  now 
brought  forward  together  over  the  face  piece  and  clamped 
in  such  a  way  as  to  include  the  latter  and  hold  it  firmly 
against  the  patient.  Cotton  is  stuffed  into  the  space 
between  the  face  and  the  towel.  By  this  arrangement 
both  hands  of  the  anaesthetist  are  free.  (While  such  a 
fixation  of  the  face  piece  would  be  unwise  with  ordinary 
ether  anaesthesia,  because  of  the  pharyngeal  relaxation 
obtaining,  in  this  very  light  form  of  maintenance,  the  re- 
tained tonicity  of  the  pharyngeal  structures  prevents  the 
obstruction  which  would  otherwise  occur.)  If  the  opera- 
tion is  to  be  on  the  neck,  a  covering,  half  sheet,  half  gauze, 
is  fastened  to  the  patient's  chin,  the  gauze  portion  being 
thrown  over  the  head  of  the  anaesthetist.  Such  a  cover- 
ing is  welcomed  by  the  anaesthetist  since  it  permits  of  much 
needed  ventilation. 

The  respiration  being  tranquil  and  the  color  good,  the 
skin  to  be  incised  is  carefully  and  completely  infiltrated 
with  a  solution  of  novocaine  1/4.00.  This  infiltration,  or 
nerve  blocking  is  conscientiously  done  with  every  tissue  en- 
countered, particular  care  being  exercised  to  inject  the 
peritoneum  and  the  pedicels  of  the  pelvic  organs,  gall- 


NITROUS  OXIDE  OXYGEN  ETHER  ANESTHESIA  247 

bladder,  etc.  A  failure  to  completely  block  the  field  of 
operation  shows  itself  in  changes  in  the  patient's  respira- 
tion, moaning,  or  slight  movements,  followed  by  rigidity. 
Retractors  are  seldom  employed  and  the  utmost  gentleness 
is  exercised  in  handling  the  tissues. 

The  administration  of  the  gas  and  oxygen  is  of  second- 
ary importance ;  we  find  that  the  chief  guide  to  be  followed 
is  the  color.  The  patient  is  the  index  as  to  the  inixture 
which  he  receives:  he  is  not  forced  to  accept  a  theoretical 
mixture.  The  nitrous  oxide  and  oxygen  are  usuallj'  made 
to  flow  continuously,  partial  rebreathing  only  being  per- 
mitted. The  limitation  of  the  rebreathing  causes  the  res- 
pirations to  be  much  more  shallow  than  when  rebreathing 
is  freely  employed.  When  a  constant  flow  is  used  N2O  is 
delivered  at  a  rate  of  about  one  hundred  gallons  an  hour, 
the  oxygen  varying  from  five  to  twenty-five  an  hour. 

The  anaesthetist  is  constantly  attended  and  assisted  by 
a  pupil  nurse  who  is  well  instructed  as  to  her  duties. 

There  being  no  confusion  in  the  status  of  the  anaes- 
thetist, as  is  frequently  the  case  when  the  junior  interne 
occupies  this  position,  the  aneesthesia  proceeds  without  an- 
noying instructions  from  the  senior  house  officers.  The 
surgeon,  appreciating  the  fact  that  the  anjesthesia  is  pri- 
marily a  local  and  secondarily  a  general  anaesthesia,  inter- 
prets undesirable  rigidity  as  due  to  incomplete  nerve  block 
rather  than  to  the  faulty  administration  of  the  gas  and  oxy- 
gen. In  cases  of  exophthalmic  goitre  the  administration  of 
the  gas  and  oxygen  is  continued  until  the  patient  has  been 
returned  to  bed  and  is  propjDcd  up  with  pillows.  Abun- 
dant assistance  is  furnished  for  the  transportation.  (As 
many  as  five  persons  assist  in  the  transportation  of  goitre 
cases  from  the  place  of  operation  to  the  room.) 


248  ANAESTHESIA 

The  addition  of  ether  in  the  early  periods  of  induction 
simplifies  the  administration  to  a  considerable  degree. 
Ether  in  small  quantities  is  not  infrequently  used  in  this 
-fashion.  Since  it  is  seldom  employed  during  recovery, 
however,  it  is  soon  rinsed  out  by  the  pure  gas  oxygen  anaes- 
thesia which  follows  and  no  ether  effects  are  apparent.  The 
free  use  of  ether  would  comjDlicate  rather  than  assist  the 
anaesthesia,  for  undesirable  relaxation  of  the  tongue  and 
pliaryngeal  structures  would  follow,  possibly  requiring  the 
removal  of  the  face  piece  for  relief. 

The  recovery  from  the  anaesthesia  is  rapid  and  com- 
plete. INIost  patients  retch  once  or  twice  before  conscious- 
ness returns.       » 


B.  LOCAL  ANAESTHESIA 

Local  ana?sthesia  is  that  type  of  anaesthesia  which  in- 
volves only  the  jjeripheral  nervous  system.  It  may  be 
brought  about  by: 

( a )    Freezing. 

(h)  Pressure  on  the  nerve  trunks  or  by  pressure  pro- 
ducing ischccmia  of  the  part. 

(c)  By  regional  intravenous  injections  of  novocaine. 

(d)  By  tlie  injection  of  novocaine  or  some  other  drug 
into  the  skin  or  deeper  tissues. 

CHAPTER  X 

UNUSUAL  METHODS 
L    LOCAL  ANAESTHESIA  BY  FREEZING 

The  effect  of  extreme  cold  applied  locally  is  to  produce 
a  loss  of  sensation  of  the  part.  This  is  a  very  common 
experience  following  exposure  to  very  low  temperatures. 
One's  ears,  for  example,  when  first  exposed  to  zero  weather 
at  first  tingle,  then  become  painful.  As  the  effect  of  the 
cold  increases,  the  pain  disaj^pears  and  the  sensation  is 
lost.  The  parts  are  then  more  or  less  anaesthetic.  They 
can  be  rubbed  or  j)inched  or  cut  without  pain.  As  thawing 
is  gradually  accomplished,  the  pain  returns  with  greatly 
increased  severity.  Even  after  complete  recovery  there 
may  be  occasional  intervals  of  transient  piun  familiarly 
known  as  chilblains. 

Freezing  may  be  artificially  brought  about  by  the  use 
of  the  ethijl  chloride  spray.  The  rate  of  evaporation  of 
this  liquid  is  so  rapid  that  the  surface  temperature  is 
brought  below  the  freezing  point  and  becomes  actually 

249 


^250  ANAESTHESIA 

frozen.  The  freezing  process  appears  to  act  as  a  termi- 
nal anassthetic  and  is  complete  in  a  few  seconds.  The  best 
results  are  obtained  by  holding  the  nozzle  of  the  sj^ray 
about  ten  inches  from  the  skin  and  by  blowing  gently  upon 
the  surface  to  assist  the  evaporation.  Freezing  is  indi- 
cated bj'  the  blanching  of  the  part  exposed  to  the  action 
of  the  spray.  AMien  cut  with  a  knife  the  tissues  will  be 
found  to  be  hard  and  somewhat  brittle.  The  degree  of 
anaesthesia  produced  by  this  method  is  variable.  It  de- 
pends largely  upon  the  degree  to  which  the  skin  is  frozen. 
As  is  the  cape  with  the  ordinary  freezing,  due  to  exposure, 
the  recovery  is  painful,  and  if  the  freezing  has  been  pro- 
tracted extensive  sloughing  is  apt  to  follow. 

II.    LOCAL  ANESTHESIA  BY  PRESSURE 

Pressure  on  nerve  trunks  produces  a  loss  of  sensation 
in  the  tissue  supplied  by  the  compressed  nerve.  This  con- 
dition often  occurs  accidently  when  pressure  is  allowed  to 
act  upon  a  suj^erficial  nerve.  Muculospiral  paralysis, 
occurring  when  an  anaesthetized  patient's  arm  is  allowed  to 
hang  over  edge  of  the  table  (Fig.  23),  produces  this  effect. 

Local  anaesthesia  may  be  brought  about  by  pressure 
interfering  with  the  circulation.  Who  has  not  awakened 
after  a  long  sleep  and  been  shocked  to  find  a  strange,  cold, 
motionless  hand  in  the  bed  beside  him,  and  who  will  forget 
the  sense  of  relief  when  this  strange  hand  proves  to  be 
his  own? 

Artificially  these  effects  have  been  jiroduced  by  pres- 
sure on  the  nerves  supplying  parts  to  be  operated  upon. 
The  practice  is  very  ancient  in  its  usage  but  the  pain 
directly  occasioned  by  the  pressure  is  so  annoying  that  the 
method  is  of  little  practical  value. 


LOCAL  ANESTHESIA 


251 


A  certain  degree  of  anaesthesia  may  be  brought  about 
artificially  by  the  employment  of  an  Esmarch  bandage, 
(Fig.  110) .  This  consists  of  a  long,  rubber  band  some  three 
inches  wide  and  six  feet  long,  which  by  being  tightly  wound 
about  the  limb  beginning  at  the  distal  end  produces  a 
bloodless  or  ischtemic  condition.    One  may  profitably  bear 


Fig.    110. — Esmarch  bandage. 

in  mind  this  fact  when  a  general  ana?sthetic  is  being  given 
for  an  amputation  of  a  limb,  which  has  been  previously 
rendered  ischa?mic  by  the  use  of  an  Esmarch  bandage. 

IIL    LOCAL  ANESTHESIA  BY  REGIONAL  INTRA- 
VENOUS INJECTIONS  OF  NOVOCAINE 

This  method  is  applicable  to  all  operations  upon  the 
extremities.  The  most  important  factor  in  the  technic  is 
to  produce  a  completely  ischfemic  condition  of  the  limb. 


252  ANESTHESIA 

Our  object  in  this  method  is  first  to  empty  the  veins 
by.  the  proper  use  of  rubber  bandages ;  secondly  to  fill  these 
emptied  veins  with  a  solution  of  5  per  cent,  novocaine. 
By  this  procedure  we  bring  not  only  the  superficial  but 
also  the  deep  structures  under  the  influence  of  the  anees- 
thetizing  solution. 

The  cephalic  or  basilic  vein  in  the  arm,  or  the  internal 
saphenous  in  the  leg,  should  be  marked  out. 

With  the  limb  raised  an  Esmarch  bandage  is  tightly 
applied  from  the  fingers  or  toes  to  a  point  above  the  site 
of  the  operation.  Where  this  bandage  ends,  a  second, 
broad  Esmarch  is  applied.  This  is  known  as  the  proximal 
bandage  (being  nearest  the  body  of  patient). 

The  first  bandage,  that  which  was  used  to  produce 
ischemia,  is  slowly  unwound;  the  unwinding  naturally 
beginning  where  it  ceased,  i.e.,  next  to  the  proximal  band- 
age and  not  at  the  fingers  or  toes.  If  some  part,  say  the 
middle  third  of  the  forearm,  is  to  be  operated  upon,  the 
bandage  is  unwound  to  just  below  this  point.  A  second, 
broad  bandage,  the  distal  bandage,  being  here  applied. 
The  space  included  between  the  two  bandages  (which 
should  be  not  less  than  10  cm.  (2^  inches)  or  more  than 
25  cm.  (10  inches) )  is  now  cut  off  from  the  venous  circula- 
tion above  and  below  (Fig.  111). 

If  the  part  to  be  operated  upon  be  the  finger  or  toe, 
the  proximal  bandage  is  applied  at  the  middle  of  the  fore- 
arm and  no  distal  bandage  is  employed  (Fig.  112). 

The  vein,  which  we  previously  marked  out,  is  now 
located  and,  under  local  anaesthesia  produced  by  novocaine, 
it  is  dissected  out  as  near  to  the  proximal  bandage  as  possi- 
ble. A  ligature  is  then  tied  here.  Using  this  ligature  as 
a  retractor,  the  vein  is  lifted  from  its  bed  and  a  small  slit 


LOCAL  ANiESTHESIA 


253 


made  in  its  lumen  by  a  pair  of  scissors.  A  syringe  capable 
of  holding  GO  c.c,  capped  with  an  ordinary  intravenous 
cannula,  is  introduced  into  the  vein  and  tied  into  place. 
Forty  to  .>0  c.c,  of  the  solution  is  then  slowly  injected. 
Anaesthesia  of  the  segment  of  the  arm  between  the  proxi- 
mal and  the  distal  ligature  is  rapid  and  complete.     The 


5m  mf?KIN6  OF  NOW  ISCHEMIC  VEIN 


rr^'^IoV^ 


Figs.  Ill  and  112. — Bandage  for  regional  intravenous. 


solution  may  be  quite  easily  forced  against  the  obstruction 
offered  by  the  valves  of  the  veins  The  veins  at  first  swol- 
len by  the  solution,  soon  collapse  indicating  the  penetra- 
tion of  the  fluid  into  the  deep  tissues.  The  anaesthesia  of 
the  part  continues  until  the  proximal  bandage  is  removed. 
The  reestablishment  of  the  circulation  is  rapidly  followed 
by  a  return  of  the  sensation. 


254  ANESTHESIA 

The  method  may  prove  serviceable  for  emergency  am- 
putations in  situations  where  a  general  ansesthetic  is  for 
one  or  more  reasons  contraindicated. 

The  method  appears  more  thorough  and  reliable  than 
that  offered  by  surface  ansesthesia,  for  the  solution  injected 
into  the  vein  reaches  and  anaesthetizes  the  deepest  struc- 
tures at  a  single  injection. 

This  method  has  been  used  more  than  .500  times  by 
different  operators  who  report  success  in  about  90  per  cent, 
of  their  cases. 


CHAPTER  XI 

USUAL  METHODS 

LOCAL  ANAESTHESIA  BY  INJECTIONS  OF  NOVOCAINS 
AND  OTHER  DRUGS  INTO  THE  SKIN  AND  DEEPER 
TISSUES 

Local  anaesthesia  is  usually  brought  about  by:  (a) 
surface  application;  (b)  by  infiltration  into  the  tissues 
(terminal  anesthesia)  ;  (c)  by  injections  into  or  around 
nerve  trunks  (conductive  or  regional  anaesthesia). 

1.  The  surface  method  is  that  usually  used  for  work 
which  involves  mucous  membranes,  i.e.,  nose  and  throat 
and  genito-urinary  operations.  Solutions  of  cocaine  .5  to 
1  per  cent,  with  adrenalin  are  the  strengths  ordinarily 
employed. 

2.  Infiltration ancesthesia  {or  terminal ancesthesia)  aims 
to  anaesthetize  the  terminal  end  organs  by  bringing  them 
into  contact  with  the  solution.  This  is  the  method  usually 
employed  for  superficial  operations. 

3.  Conductive  ancesthesia  or  regional  ancesthesia  aims 
to  destroy  or  directly  block  the  conductivity  of  the  nerves 
which  supply  the  part  to  be  operated  upon.  This  is  per- 
formed by  endoneurial  injections  (direct  injections  into 
the  nerves)  or  perineuria!  injections  (bathing  the  nerve 
trunks  with  the  solution) .  This  method  is  often  combined 
with  terminal  ancesthesia. 

IXFILTRATIO'N  OR  TERMINAL  AN/ESTHESIA 

Water  injected  under  the  skin  causes  a  transient  anaes- 
thesia. This  is  painful  of  accomplishment  and  unsatis- 
factory.    Solutions  of  the  same  specific  gravity  as  the 

255 


256  ANiESTHESIA 

tissues  will  not  produce  anaesthesia  per  se;  such  solutions, 
normal  saline  for  example,  must  contain  an  anaesthetic 
drug  to  be  effective.  If  the  injected  fluid  which  we  em- 
ploy is  rapidly  absorbed  its  effect  will  be  unsatisfactory. 
To  limit  this  rapid  absorption  adrenalin  is  habitually 
added  to  the  solution.  The  solution  should  also  be  capa- 
ble of  repeated  sterilization. 

The  Solutions  Used. — Cocaine. — Strength  com- 
monly used  1  per  cent,  to  1/10  of  1  per  cent.  The  solu- 
tion may  be  made  up  from  standard  tablets  or  from 
Bodines'  tubes.  The  latter  are  composed  of  cocaine  and 
sodium  chloride  in  such  proportion  that  when  mixed  with 
sterile  water  a  solution  ready  for  immediate  use  is  formed. 

Novocaine. — Strength  commonly  used  .5  per  cent.  It 
is  the  most  widety  used  of  all  drugs  for  local  anaesthesia 
and  ten  times  safer  than  cocaine.  Its  solution  may  be 
repeatedly  boiled.  It  may  be  conveniently  had  in  tablet 
form  marketed  as  novocaine  suprarenin  tablets.  These 
tablets  are  supposed  to  be  sterile  but  it  is  safer  to  boil  the 
solution  in  which  they  are  dissolved. 

Qiiinine  and  Urea. — Strength  commonl}^  used  .5  to 
1  per  cent.  This  solution  is  said  to  be  absolutely  non- 
toxic. The  anaesthetic  effects  which  it  produces  are  more 
lasting  than  those  of  cocaine  or  novocaine.  Because  of 
this  prolonged  effect  it  is  often  used  with  a  view  of  control- 
ling post-operative  pain.  Some  have  claimed  that  it  helps 
to  control  hemorrhage  after  operation  by  causing  a  deposit 
of  fibrin  over  the  exposed  vessels;  others  have  contended 
that  its  employment  interfered  with  the  healing  of  the 
tissues.  If  one  wishes  a  prolonged  action  it  is  well  to  wait 
fifteen  to  twenty  minutes  before  incising  the  tissues 
inj  ected. 


USUAL  METHODS 


257 


The  Syringe. — The  ordinary  hypodermic  syringe  of 
ull  glass  or  metal  is  entirely  satisfactory  (Fig.  113). 
Syringes  should  be  boiled  in  plain  water  and  after  using 
dried  carefully  and  a  drop  of  castor  oil  run  in.  This  pre- 
vents the  sticking  of  the  piston  in  the  all  glass  syringe  and 
the  drying  out  of  the  packing  in  the  metal  syringe. 


Fig.    113. — Case  contaiaing  outfit  for  intraspinal  and  local  anaesthesia.     (Steel,  International 

Clinics.') 

Needles. — Steel  needles  are  satisfactory.  A  variety 
of  sizes  should  be  on  hand.  These  should  range  from  the 
ordinary  short  hypodermic  needles  to  those  10  cm.  in 
length.  Nickel  and  platinum  needles  may  be  had,  and  by 
their  longer  life  are  worth  the  difference  in  the  purchase 
price. 

The  Preliminary  Treatment  of  the  Patient  who 
IS  to  Receipt?:  the  Infiltration  (Terminal)  or  the 
Conductive  (Regional)  Anesthesia. — An  hour  before 

17 


258  ANESTHESIA 

operation  a  dose  of  morphine  gr.  Yg  and  scopolamine  gr. 
1/200  should  be  given. 

The  operation,  no  matter  how  trivial,  should  be  invaria- 
bly done  with  the  patient  lying  down. 

The  patient  should  have  a  cup  of  soup  or  milk.  It  is 
best  not  to  operate  on  an  empty  stomach. 

It  will  be  readily  understood  that  the  proper  employ- 
ment of  suggestion  is  most  important.  This  applies  not 
only  to  the  immediate  treatment  of  the  individual  but 
especially  to  the  provision  of  a  proper  environment,  quiet, 
courtesy  and  the  banishment  of  disagreeable  sights. 

Every  effort  should  be  made  to  distract  the  attention 
of  the  patient.  If  one  is  acquainted  with  his  habits  and 
sphere  of  life,  conversation  proceeds  more  freely.  A  sip 
of  water  or  vichy  may  be  permitted  now  and  then.  Some 
operators  allow  their  patient  to  smoke. 

Operations  done  under  local  anaesthesia  need  not  be 
hastened.  Great  care  and  gentleness  should  be  exercised 
in  the  use  of  retractors  and  in  sponging. 

The  Administration  of  Infiltratiox  (Terminal) 
Anesthesia. — A  syringe  is  filled  with  the  desired  solu- 
tion, and  the  needle  is  introduced  just  beneath  the  skin 
and  nearly  parallel  to  it.  The  solution  is  forced  into  the 
tissue  and  should  form  a  small,  blanched  elevation  or  weal. 
The  needle  is  withdrawn  and  reintroduced  into  the  hoi'der 
of  this  weal,  7iot  into  a  portion  of  the  uninjected  skin. 
If  one  follows  the  practice  of  reintroducing  the  needle 
each  time  into  the  weal,  the  only  pain  which  the  patient 
will  experience  will  be  the  initial  introduction.  It  is  sug- 
gested that  novocaine  solutions  be  dyed  so  that  the  limit 
of  its  penetration  into  the  tissue  may  be  easily  seen.  When 
the  desired  area  has  been  injected,  the  skin  will  be  found 


USU.\L  METHODS 


259 


to  be  anaesthetized.  Great  care  should  he  exercised  to  see 
that  the  incision  does  not  extend  beyond  the  amesthetized 
area.  The  anaesthesia  tluis  produced  will  last  for  two  or 
three  hours.  Tissues,  whose  sensitiveness  we  know  to  be 
acute,  should  be  carefully  injected  before  they  are  touched 
with  the  knife  or  sponged  (Fig.  114). 


LEAST  SENSITIVE 
fat 

fencfons 
fasc/cx  — 

v/\sc<zr£>/ 
P^r'itane 

bone. 


MOST  SENSITIVE 

par/<z  ta/ 
p<z.r/f-one.am 

b/ood 


p^r/ostearr? 
•Synov'/a/ 

mzmbrcirie, 
Cart/ca/ar  Surface) 

Fig.   114. — Relative  sensitiveness  of  tissues.     (Modified  from  Cunningham's  Anatomy.) 

The  slxin  is  everywhere  sensitive. 

The  jat,  muscles,  tendons  and  fascia  where  nerve 
trunks  and  blood  vessels  are  not  included,  are  insensi- 
tive. 

The  parietal  peritoneum  is  very  sensitive,  but  the  vis- 
ceral peritoneum  is  insensitive. 

Periosteum  and  synovial  membranes  are  very  sensi- 
tive. 

Bone  and  cartilage  are  not  sensitive. 

The  Administration  of  Conducti\t:  or  Regionai. 
Anesthesia. — Conductive  anaesthesia  implies  a  precise 
knowledge  of  the  distribution  of  the  nerves  supplying  the 
part  to  be  operated  on.  Perineurial  injections  are  quite 
easily  made.  The  time  required  for  aUcEsthesia  and  the 
strength  of  the  solution  depend  upon  the  size  of  the  nerve 


260  ANAESTHESIA 

to  be  blocked.  Strong  solutions  .5  to  1  per  cent,  cocaine 
are  used  about  large  trunks.  By  the  employment  of  con- 
ductive ana?sthesia,  boils  or  ulcers  may  be  blocked  at  a  dis- 
tance and  the  incision  or  the  excision  of  the  same  rendered 
painless.  In  endoneural  injections  the  nerve  should  be 
dissected  out  and  the  needle  pointing  centrally  thrust  into 
it.  The  solution  is  then  injected  until  the  nerve  swells. 
If  the  needle  points  peripherally,  pain  from  traction  is 
likely  to  occur.  Pain  is  not  marked  upon  injection  and 
the  conductivity  is  immediately  and  completely  blocked. 

Healing  ix  Both  Conductive  and  Terminal 
Methods. — The  accidental  use  of  saturated  saline  solu- 
tion instead  of  normal  saline  has  occasioned  sloughing  of 
the  tissues.  Some  operators  have  reported  delayed  union 
where  quinine  and  urea  have  been  employed.  As  a  rule, 
however,  the  healing  is  rapid  and  entirely  satisfactory. 

The  combined  Local  and  General  Ancesthesia  Technic 
of  Anoci  Association  as  advocated  by  Dr.  Crile  of  Cleve- 
land has  been  discussed  on  page  244. 


C.  MIXED  ANAESTHESIA 
CHAPTER  XII 

GENERAL  CONSIDERATION 

Mixed  ancTsthesia  is  that  type  of  anesthesia  in  which 
both  the  central  nervous  system  (the  spinal  cord)  and  the 
peripheral  nervous  system  are  brought  under  the  influence 
of  the  anaesthetic. 

This  type  of  anaesthesia  is  popularly  known  as  spinal 
ancesthesia  or  analgesia. 

Mixed  ana?sthesia  is  brought  about  by  injecting  the 
anaesthetizing  solution  directly  into  the  subarachnoid 
space.  Here  it  mixes  with  the  cerebrospinal  fluid.  The 
cerebrospinal  fluid,  containing  the  dissolved  anaesthetic, 
may  then  be  said  to  act  as  does  conductive  or  regional 
anaesthesia,  where  perineurial  injections  are  employed  (see 
page  2.59). 

The  situation  in  this  case  is  quite  different,  however, 
from  that  of  ordinary  local  anaesthesia  for  the  following 
reasons : 

1.  The  entire  dose  must  be  given  at  once. 

2.  The  injection  is  made  into  a  diffusible  medium,  i.e.^, 
into  the  cerebrospinal  fluid. 

3.  The  effects  sought  for  and  ordinarily  produced  are 
limited  to  a  loss  of  the  sense  of  pain.  The  appreciation 
of  heat  and  cold  and  of  pressure  and  traction  are  often 
retained. 

4.  Nerve  cells,  as  well  as  fibres,  are  exposed  to  the 
action  of  the  anaesthetic. 

261 


262  ANESTHESIA 

The  puncture  of  the  spinal  cord  and  the  injection  of 
the  analgesic  solution  imply  a  knowledge  of  the  anatomy 
of  the  part.  While  the  dose  may  be  repeated,  if  the  first 
dose  proves  inefficient,  it  cannot  be  repeated  ad  libitum. 
On  the  other  hand,  it  is  impossible  to  withdraw  an  overdose. 

A  solution  of  a  lower  specific  gravity  than  the  cerebro- 
spinal fluid  is  known  as  a  diffusible  solution.  These  solu- 
tions are  usually  made  up  of  the  anesthetic  drug,  water 
and  alcohol.  Such  diffusible  solutions  are  employed  for 
analgesia  required  above  the  point  of  injection,  i.e.,  for 
neck  and  head  operations.  We  mention  this  type  of  solu- 
tion only  to  condemn  it. 

When  the  operation  is  to  be  in  the  lower  limbs  a  solu- 
tion containing  glucose  is  sometimes  used.  The  addition 
of  glucose  is  for  the  purpose  of  increasing  the  specific 
gravity  of  the  injected  solution.  Such  a  solution  is  known 
as  a  non-diffusible  solution. 

The  cerebrospinal  fluid  is  a  secretion  of  the  choroid 
plexus  and  the  ependymal  membrane  (membrane  lining 
the  central  canal  of  the  cord).  The  amount  of  the  fluid 
varies  from  50  to  150  c.c.  The  specific  gravity  is  vari- 
ously estimated  at  1.004  to  1.007,  increasing  with  the  age 
of  the  patient.  The  cerebrospinal  fluid  is  constantly  in 
motion  and  under  a  pressure  varying  from  50  to  150  mm. 
of  water. 

The  diffusion  of  the  injected  fluid  depends  upon  the 
concentration  and  the  pressure  with  which  the  injection  is 
made.  The  diffusion  occurs  very  rapidly  where  marked 
pressure  is  made. 

The  head  down  position  also  increases  diffusion,  par- 
ticularly in  the  case  of  a  solution  heavier  than  the  cerebro- 
spinal fluid. 


MIXED  ANESTHESIA  263 

Unless  one  is  prepared  for  analgesia,  loss  of  pain  sense 
rather  than  aiucsthesia,  loss  of  all  sensation,  the  active 
responses  to  traction  and  preparation  of  the  patient  with 
hot  water  are  likely  to  prove  disturbing.  It  is  unwise,  how- 
ever, to  ask  the  patient  whether  or  not  he  still  feels  pain, 
as  pressure  may  be  so  interpreted  by  a  nervous  individual. 

The  fact  that  the  nerve  cells,  not  only  in  the  cord  but 
in  the  base  of  the  brain  as  well,  are  exposed  to  the  action 
of  the  amesthetic  solution,  introduces  a  complicating  factor 
and  one  which  increases  the  danger  of  the  general  employ- 
ment of  the  method.  Degenerative  effects  have  shown 
themselves  in  the  form  of  permanent  paralysis  and  in 
paresis. 

By  means  of  mixed  or  spinal  analgesia  it  has  been 
possible  to  render  the  entire  body  insensitive  to  pain. 
Operations  upon  the  head  and  neck  as  well  as  upon  the 
extremities  have  been  done  painlessly.  High  analgesia, 
above  the  diaphragm,  occurs  where  a  concentrated  solution 
has  been  given  under  pressure.  Because  of  the  danger 
of  paralysis  of  the  respiration,  analgesic  effects  above  the 
umbilicus  should  not  be  tolerated. 

The  method  has  been  used,  and  with  satisfaction,  in 
children. 

Apparatus 

1.  Suitable  syringe  and  two  cannul^e. 

2.  Solution  for  injection. 

3.  Ethyl  chloride  spray  or  local  ansesthesia  accessories 
for  novocaine  injection  of  the  skin. 

4.  Hypodermic  of  strychnine  1  30  and  camphor  in  oil. 

5.  Sterile  adhesive  or  collodion  for  sealing  punctui'e. 
1.  Complete  set  of  suitable  syringes  and  needles  may 

easily  be  had  (Fig.  113). 


264,  ANESTHESIA 

2.  Since  cocaine  and  stovaine  solutions  have  given  way 
to  the  less  toxic  novocaine  and  tropacocaine,  it  will  hardly 
be  to  our  advantage  to  consider  the  former.  Vials  of 
novocaine,  5  per  cent,  solution,  containing  3  c.c.  each,  will 
be  found  satisfactory. 

The  novocaine  tablet  C,  also  for  sale,  is  very  con- 
venient. The  minimum  dose  is  2  c.c,  average  dose  2.5  c.c, 
maximmn  dose  3  c.c 

Vials  of  tropacocaine  5  per  cent,  solution,  containing 
1  c.c  each,  are  on  the  market  and  will  be  found  satisfactory. 
The  minimum  dose,  one  vial  1  c.c,  maximum  dose,  two 
vials  2  c.c. 

Both  of  the  above  solutions  contain  adrenalin. 

When  the  syringe  and  needles  are  boiled  one  should 
he  careful  to  have  no  soda  in  the  water,  as  an  alkaline  solu- 
tion destroys  the  solutions  of  both  the  above  drugs. 


CHAPTER  XIII 
THE  ADMINISTRATION 

It  is  perfectly  feasible  to  carry  out  the  administration 
without  any  preliminary  preparation  whatever. 

When  possible,  however,  psychic  treatment  should  be 
employed,  every  means  being  used  to  gain  the  confidence 
of  the  patient.  It  is  advisable  to  give  a  dose  of  morphine 
gr.  ys  ^^^^  hyoscine  1/200  an  hour  before  operation. 
Strychnine  gr.  1/60  and  nitroglycerine  gr.  1/100  may  "be 
used  to  advantage.  It  is  not  necessary  that  the  patient 
fast. 

The  most  satisfactory  site  of  injection  is  between  the 
third  and  the  fourth  lumbar  vertebrae  directly  in  the  middle 
line  (Fig.  117).  The  object  of  this  site  of  injection  is  to 
immediateh^  engage  the  ligamentum  muscle.  This  facili- 
tates the  direct  entrance  into  the  canal. 

This  point  may  be  found  as  f ollow  s :  With  the  patient 
sitting  up  in  a  slouching  posture,  draw  a  line  connecting 
both  iliac  crests.  This  line  will  cross  the  spinous  process 
of  the  fourth  lumbar  vertebra  (Fig.  116).  The  point 
of  injection  is  then  just  above  this  line.  The  site  of 
injection  having  been  located,  the  area  is  then  painted 
with  iodine  and  a  slit  sheet  placed  over  all.  The  jDatient 
with  the  arms  folded  across  the  abdomen  is  instructed  to 
learn  forward  bending  the  neck  on  the  chest.  This  atti- 
tude serves  to  increase  the  spaces  between  the  spines.  The 
skin  is  now  sprayed  "vvith  ethyl  chloride  and  a  small  nick 
made  with  a  scalpel.  The  cannula  with  the  mandril  or  stylet 

265 


Fig.    115. — The  relations  of  the  lumbar  and  dorsal  interspiices  to  the  crests  of  the  ilia  and  lower 
ribs.     (Steel,  International  Clinics.) 


THE  ADMINISTRATION 


267 


-t 


Fig.  116. — Localization  of  the  spinal  interspaces.  With  the  patient  bent  forward,  a  towel  stretched 
between  the  iliac  crests  passes  through  the  spine  of  the  fourth  lumbar  vertebra.  The  first  lumbar  in- 
terspace is  opposite  the  tip  of  the  last  rib.     (Steel,  International  Clinics.) 


268  ANAESTHESIA 

in  place  is  then  inserted.  The  needle  is  directed  forward 
and  inward.  One  feels  a  sense  of  resistance  followed  by  a 
sudden  pop  as  the  needle  enters  the  canal.  The  mandril 
should  then  be  withdrawn.  If  the  needle  is  in  the  canal 
fluid  will  escape.  If  no  fluid  escapes  one  should  replace 
the  mandril  again,  insert  and  withdraw  until,  upon  the 
partial  withdrawal  of  the  mandril,  fluid  escapes.  Ten  or 
fifteen  drops  of  cerebrospinal  fluid  may  be  permitted  to 
escape  out  of  the  end  of  the  cannula.  The  syringe,  loaded 
with  the  solution,  novocaine  or  tropacocaine,  is  then 
attached  and  a  little  of  the  cerebrospinal  fluid  is  with- 
drawn (Fig.  119).  The  syringe  with  the  mixture  is  then 
detached  to  see  that  the  needle  is  still  in  the  canal.  If 
spinal  fluid  flows  out  the  syringe  may  be  reattached  and 
the  injection  made  under  moderate  pressure.  The  greater 
the  pressure  the  higher  will  be  the  anaesthesia.  The  patient 
should  then  be  placed  in  the  semi-sitting  position.  The 
procedure  is  completed  by  sealing  the  wound  by  adhesive 
or  collodion. 

Shortly  after  the  injection  the  following  symptoms 
may  be  expected :  Tingling  of  the  feet,  a  sense  of  general 
malaise,  nausea  and  vomiting.  These  symptoms  may  be 
marked  or  of  no  consequence.  Following  the  tingling  in 
the  feet,  analgesia  and  loss  of  motor  power  will  make  their 
appearance  beginning  below  and  extending  upward.  Pal- 
lor and  perspiration  are  occasionally  seen.  At  the  first 
appearance  of  any  symptom,  however  slight,  the  patient 
should  receive  immediately  a  hypodermic  injection  of 
strychnine  gr.  1/30. 

An  overdose  may  be  treated  by  inhalations  of  ether 
carried  to  the  period  of  excitement. 


THE  ADMINISTRATION 


2G9 


H 


Fio.  117. — The  point  of  skin  puncture  is  anaesthetized  by  freezing;  this  is  not  necessary  if  a 
fine  needle  is  used.     (Steel,  International  Clinics.) 


ANAESTHESIA 


Fig.   lis. — The  needle  is  introduced  in  the  middle  line  forward  and  inward.     (Steel,  International 

Clinics.) 


THE  ADMINISTRATION 


271 


Fig.  1 19. — As  the  dura  is  pierced,  the  cerebro.spinal  fluid  escapes  and  may  be  collected  in  test- 
tube  for  further  study.     (Steel,  International  Clinics.) 


The  Advantages  of  the  Method 

1.  When  acting  satisfactorily  it  insures  a  quiet  field  of 
operation. 

2.  Reduces  the  amount  of  after-sickness. 

3.  The  necessary  apparatus  is  comparatively  simple. 

4.  May  prove  of  value  where  there  is  an  absolute  con- 


272 


ANESTHESIA 


Fig.   120. — The  syringe  containing  the  proner  dose  of  stovaine  is  attached  to  the  needle  and 
slowly  injected.     (Steel,  International  Clinics.) 


THE  ADMINISTRATION  273 

traindication  to  an  anaesthetic,  or  where  one  is  confronted 
with  an  inexperienced  anaesthetist  and  a  bad  subject  for 
general  anaesthesia. 

The  Disadvantages  of  the  Method 

1.  An  overdose  cannot  be  withdrawn. 

2.  The  duration  and  the  degree  of  the  analgesia  or  the 
anaesthesia  cannot  be  depended  upon. 

3.  The  amount  of  the  drug  necessary  to  produce  the 
desired  result  is  not  absolutely  known. 

4.  There  is  at  times  incomplete  muscular  relaxation. 

5.  There  is  danger  in  the  injection  of  a  heterogeneous 
fluid  into  the  spinal  canal. 

6.  Its  expert  use  requires  experience  which  must  be 
gained  by  trials  upon  patients  who  present  no  special  indi- 
cations for  the  method. 

7.  There  is  danger  of  subsequent  paresis  and  local  or 
general  paralysis. 

8.  The  induction  is  frequently  unpleasant  for  the 
patient  and  the  persistence  of  consciousness  may  prove 
undesirable. 


18 


PART  II 

BEARING   UPON  FACTORS    INCIDENTAL   TO   THE 
ACTUAL  ADMINISTRATION  OF  THE  ANAESTHETIC 


CHAPTER  XIV 

PRELIMINARY  MEDICATION  IN  ANESTHESIA 

By  preliminary  medication  we  mean  that  medication 
which  is  given  before  the  aneesthetic  has  been  induced. 
Drugs  so  administered  are  usually  given  hypodermically, 
for  by  this  method  they  act  more  speedily  and  with  greater 
constancy. 

Drugs,  Doses  and  Time  of  Administration 

The  most  common  preliminary  medication  is  by  mor- 
phine and  atropine.  The  ordinary  dose  of  morphine  is 
grs.  ylf  of  atropine  grs.  1/150.  If  indications  call  for  a 
smaller  dose,  the  above  standard  tablet  is  dissolved  in  a 
hypodermic  syringe,  and  one-half  or  two-thirds  of  the 
entire  solution  is  given.  The  usual  time  of  administration 
is  twenty  minutes  before  operation.  Some  prefer  a  two 
hour  interval. 

The  next  most  common  preliminary  medication  is  that 
by  morphine  and  scopolamine  (hyoscine).  Scopolamine 
and  hyoscine  are  thought  to  be  identical.  The  maximum 
dose  of  morphine  is  %  grs.,  of  hyoscine  1/100  grs.  The 
dose  ordinarily  administered  is  two-thirds  of  the  maximum 
dose.  The  time  of  administration  is  one  hour  before 
operation. 

Preliminary  medication  is  sometimes  given  by  mouth 
in  the  form  of  triple  bromides ;  ten  grains  every  four  hours 
for  three  doses  before  operation  may  be  given,  where  the 
patient  is  unusually  nervous  and  apprehensive.  Veronal, 
the  evening  before  the  operation,  in  doses  of  7  grs.  dis- 
solved in  hot  milk  will  be  found  of  value,  where  insonmia 
is  to  be  expected. 

277 


278  ANAESTHESIA 

General  Considerations 

The  entire  question  of  preliminary  hypodermic  medi- 
cation appears  to  depend  upon  whether  the  administration 
of  the  auccsthetic  is  to  be  the  open  or  closed  method.  In 
other  words,  the  situation  is  dependent  upon  the  amount 
of  rebreathing  which  the  patient  experiences.  Those  who 
have  written  for  and  against  the  use  of  preliminary  hypo- 
dermic medication  do  not  sufficiently  emphasize  the  method 
which  they  customarily  employ  in  the  administration  of  the 
ansesthetic.  Anaesthetists,  who  use  the  open  or  semi-open 
drop  method  to  the  exclusion  of  the  closed  method,  natu- 
rally see  the  maximum  ill  effects.  On  the  other  hand, 
those  who  habitually  make  use  of  strictly  closed  methods, 
see  untoward  phenomena  so  infrequently  that  they  are 
liable  to  discount  their  occurrence.  If  the  influence  of 
rebreathing  or  CO2  stimulation  upon  narcotized  subjects 
be  more  fully  appreciated,  this  confusion  of  judgment 
will  not  so  frequently  occur. 

Experiments  upon  dogs  and  other  small,  hairy  animals, 
by  virtue  of  the  more  extensive  functions  of  the  lungs  in 
throwing  off  moisture,  heat,  etc.,  render  experiments 
directed  to  respiratory  phenomena  in  human  beings  of  less 
value  than  was  formerly  supposed.  In  glancing  over  the 
materia  medica,  we  find  the  action  of  morphine,  atropine 
and  scopolamine  to  be  most  complex.  Almost  every  sys- 
tem and  every  organ  is  affected.  To  attempt  to  catalogue 
these  effects,  or  to  attempt  to  neutralize  supposed  effects 
by  other  supposed  effects  is  likely  to  result  in  confusion. 
Where  the  action  of  these  drugs  may  be  calmly  studied  in 
the  normal  subject,  complicated  only  by  age,  idiosyncrasy, 
dosage  and  purity  of  the  drugs  used,  our  task  is  sufficiently 
difficult.     Where,  however,  we  superimpose  upon  these 


PRELIMINARY  MEDICATION  IN  ANESTHESIA      279 

complications  an  anaesthetic,  incidental  respiratory  obstruc- 
tion, the  absence  or  presence  of  rebreathing,  operative 
trauma,  posture  of  the  patient  and  the  difficulty  of  calm 
observation,  our  problem  becomes  very  complex  indeed. 
To  depend  solely  upon  the  pharmacological  action  of  a 
drug,  or  upon  a  combination  of  drugs,  to  determine  our 
attitude  toward  preliminary  hypodermic  medication  in 
anaesthesia  is  misleading. 

Above  the  mass  of  information  which  lends  itself  for 
observation  in  such  cases,  there  appear  certain  facts  which 
are  quite  constant  and  which  respond  to  certain  forms  of 
treatment. 

Where  preliminary  medication  is  used : 

(a)  The  respiration  is  depressed.  This  depression 
often  tends  to  delay  the  period  of  induction.  If  the  open  or 
semi-open  drop  method  is  used,  this  depression  continues 
and  becomes  more  pronounced  as  anaesthesia  progresses.  If 
the  closed  method  is  used,  and  rebreathing  freely  permitted, 
the  respiration  is  seldom  depressed,  the  quality  depending 
upon  the  amount  of  rebreathing  permitted. 

{b)  If  atropine  is  included  in  the  preliminary  medica- 
tion, the  secretions  are  checked.  The  saliva  and  mucus 
in  the  throat  are  markedly  diminished  or  absent,  even  in  the 
face  of  a  stormy  induction. 

(c)  The  excitement,  incidental  to  the  stage  of  induc- 
tion, is  diminished.  This  is  particularly  true  of  athletes 
and  alcoholics.  The  psychic  fear  of  operation  is  also 
largely  dispelled. 

(d)  The  amount  and  concentration  of  the  anaesthetic 
used  may  be  reduced. 

(e)  It  is  said  that  if  morphine  is  given  before  opera- 
tion, the  acidosis  consequent  to  the  operation  is  diminished. 
If  given  after  operation,  no  such  beneficial  effect  follows. 


280  ANAESTHESIA 

(/)  After  the  return  of  the  reflexes,  the  patient  often 
sinks  into  a  deep  sleep  which  delays  the  return  of  conscious- 
ness. This  effect  is  not  altogether  undesirable.  Where 
an  open  or  semi-open  administration  has  been  carried  on, 
the  rate  of  the  respirations  at  this  stage  is  likely  to  drop 
alarmingly.  Where  rebreathing  has  been  permitted  this 
is  not  so  likely  to  take  place. 

(g)  Susceptible  patients  may  vomit  more  or  less  fre- 
quently from  the  use  of  morphine  per  se. 

Some  surgeons  give  morphine  and  atropine  just  before 
the  conclusion  of  the  operation,  with  the  view  of  sparing 
the  patient  post-operative  pain.  Such  treatment  can  do 
no  harm  where  the  open  method  is  employed.  When  the 
closed  method  is  in  use,  however,  such  medication  is  not 
used  to  the  best  advantage.  A  much  more  satisfactory, 
all-round  result  is  attained  when  given  twenty  minutes 
before  operation.  If,  during  the  course  of  an  open  method 
administration,  the  respirations  become  slow  and  shallow, 
the  condition  becomes  a  difficult  one  to  meet.  Some 
method  of  rebreathing  must  be  resorted  to.  Should  the 
same  condition  occur  in  the  course  of  a  closed  adminis- 
tration, a  ready  improvement  will  be  noted  upon  increas- 
ing the  rebreathing,  and  using  oxygen  with  the  gases 
rebreathed.  We  not  uncommonly  meet  the  following 
conditions : 

A  large,  full-blooded  patient  is  given  preliminary  medi- 
cation. The  stage  of  induction  proceeds  slowly,  for  the 
respirations  are  shallow.  The  shallow  respirations  further- 
more induce  a  variable  amount  of  duskiness.  Free  re- 
breathing into  the  closed  apparatus  cannot  be  carried  on 
because,  the  more  the  patient  rebreathes,  the  more  dusky  he 
becomes.  He  cannot  be  carried  satisfactorily  upon  an 
open  method  because  the  respirations  are  so  shallow  that  he 


PRELIMINARY  MEDICATION  IN  ANAESTHESIA      281 

does  not  get  sufficient  ether.  If  oxygen  be  admitted  to  the 
rebreathing  bag,  the  difficulty  will  be  entireh^  obviated  for 
then  rebreatliing  may  be  freely  employed.  The  respira- 
tions become  deep  and  the  color  immediately  clears.  This 
treatment  is  not  mere  theory  but  constant  practice. 

The  Detailed  Effect  of  Preliminary  Morphine  and 
Atropine  upon  the  Signs  of  Anesthesia,  When 
Ether  by  the  Closed  Method  is  Used 

Induction. — The  period  of  excitement  is  short  and 
mild  in  character. 

The  period  of  rigidity  may  be  shortened  or  protracted, 
depending  entirely  upon  the  character  of  the  respiration. 

The  period  of  relaxation.  The  duration  of  this  stage 
is  also  dependent  upon  the  character  of  the  respiration. 
In  a  general  way  it  may  be  said  that  the  stage  of  induc- 
tion is  smoother  but  not  always  shorter. 

Respi?'ation. — Usually  more  shallow  and  slower.  Does 
not  respond  as  readily  to  the  stimulating  effect  of  ether. 

Color. — Largely  dependent  upon  the  character  of  the 
respiration. 

Relajcation. — Rigidity  may  be  persistent.  Ordinarily 
muscular  relaxation  is  rapid  and  complete.  Relaxation  of 
the  upper  lid  and  masseteric  relaxation  appear  early. 

Eyes. — Eyeballs  become  fixed  soon  after  consciousness 
is  lost.  The  light  reflex  is  unaffected.  The  conjunctivo- 
palpebral  and  corneal  reflexes  soon  disappear  and  are 
characteristically  sluggish.  The  pupils  are  less  likely  to 
respond  to  sympathetic  stimulation  and  widely  dilate,  as 
is  occasionally  the  case  where  morphine  is  not  used.  They 
are  frequently  pin  point  from  the  start. 

Pulse. — Of  no  special  significance  unless  unusually 
slow. 


282  ANESTHESIA 

Maintenance. — Respiration. — If  rebreathing  is  prop- 
erly employed  there  may  be  little  difference  noted  during 
this  stage.  The  respirations  do  not  respond  as  readily  to 
an  increase  or  decrease  of  ether  where  morphine  is  em- 
ployed. The  rhythm  may  be  more  or  less  affected,  even 
in  the  presence  of  normal  rate  and  amplitude. 

Color. — There  may  be  a  persistent  tendency  to  duski- 
ness. This  can  only  be  properly  relieved  by  the  use  of 
rebreathing  and  oxygen.  It  should  be  recalled  that  duski- 
ness does  not  necessarily  mean  an  excess  of  carbon  dioxide 
(see  page  298). 

Relaa'ation. — If  the  relaxation  is  once  complete  it  has 
a  tendency  to  remain  so.  Masseteric  relaxation  is  usually 
maintained  with  ease. 

Eyes. — Eyeballs  remain  fixed.  Rolling  eyes  need 
not  cause  as  much  concern  as  where  morphine  is  not 
used,  for  a  lighter  anaesthesia  may  be  carried  with  less  risk 
of  the  patient  "  coming  out."  The  light  reflex  may  be 
sluggish  or  lost.  The  corneal  reflex  often  fails  to  act  in 
the  usual  satisfactory  manner,  and  is  sluggish  or  absent 
out  of  j^roportion  to  the  depth  of  the  anaesthesia.  The 
pupils  are  almost  always  contracted,  sometimes  pin  point. 
Dilated  pujnls,  where  morphine  has  been  used,  almost 
always  mean  a  profound  degree  of  anaesthesia. 

Pulse. — The  pulse  is  ordinarily  little  affected  by  the 
operative  trauma,  even  in  a  comparatively  light  anaesthesia. 

Recovery. — Respirations. — Characteristically  shallow 
and  occasionally  irregular.  Between  the  return  of  the 
reflexes  and  return  of  consciousness  the  rate  may  drop  to 
six  or  eight  a  minute. 

Color. — Very  likely  to  be  unsatisfactory,  especially  if 
the  respiration  has  been  depressed  throughout. 

Relaocation. — Complete  and  persistent. 


PRELIMLNARY  MEDICATION  IN  AN.ESTHESL\      283 

Eyes. — Motion  of  eyeballs  begins  early.  The  light 
reflex  and  the  corneal  reflex  continue  sluggish  for  some 
time.     The  pujjil  has  a  tendency  to  remain  pin  point. 

Pulse. — Xot  characteristic. 

When  the  open  method  is  employed  with  morphine  and 
atropine  as  preliminary  medication,  the  untoward  signs  and 
symptoms,  which  are  observed  with  the  closed  method,  are 
aggravated.  The  respiration  in  particular  is  likely  to 
fail.  Induction  is  prolonged,  maintenance  is  often  a 
source  of  anxiety  and  recovery  is  ordinarily  delayed. 

Where  scopolamine  is  added  to  the  morphine,  the 
depressing  effect  of  the  latter  is  augmented.  It  is  a 
dangerous  practice  to  employ  preliminary  medication  by 
morphine  and  scopolamine  where  the  open  or  semi-open 
method  is  to  be  used.  Where  the  closed  method  is  em- 
ployed, with  such  preliminary  medication,  we  are  exposing 
the  patient  to  more  than  ordinary  risk. 

Preliminary  Medicatiox  Where  Nitrous  Oxide  and 

OXYGEX   is   the   Ax.ESTHETIC 

The  use  of  preliminary  medication  by  morphine  and 
atropine  and  occasionally  by  morphine  and  scopolamine  is 
positively  necessary  where  nitrous  oxide  and  oxygen  are 
used  alone,  and  where  a  smooth  and  prolonged  anaesthesia 
is  desired.  A^^len  ether  is  employed  in  conjunction  with 
these  gases,  the  need  of  preliminary  medication  is  not  quite 
so  imperative  but  is  of  distinct  beneflt.  There  is  of  course 
no  choice  between  the  open  and  closed  method  where  these 
gases  are  employed.  The  closed  method  must  be  used. 
Where  a  continuous  flow  and  little,  if  any,  rebreathing  is 
used,  the  open  method  may  be  simulated.  With  such  a 
method  it  seems  unwise  to  employ  scopolamine  as  a  routine. 

If  morphine  and  scopolamine  are  used,  the  return  to 


284  ANAESTHESIA 

consciousness  is  delayed.  Where  indicated,  however,  it  is 
very  satisfactory. 

Since  the  signs  of  anaesthesia,  when  morphine  and 
atropine  or  morphine  and  scopolamine  are  used  with 
nitrous  oxide  oxygen  anaesthesia,  are  nothing  more  or  less 
than  the  typical  gas  oxygen  anaesthesia  described  on  page 
218,  no  special  analysis  is  necessary. 

Where  chloroform  or  ethyl  chloride  are  used  to  induce 
or  maintain  anaesthesia,  preliminary  medication  should  not 
be  used. 

Preliminary  morphine  and  atropine  or  morphine  and 
scopolamine  are  contraindicated : 

Where  the  open  method  is  used. 

In  the  extremes  of  age. 

AVhere  idiosyncrasy  to  the  drugs  exists. 

Where  oxygen  cannot  be  conveniently  had. 

When  the  anesthetist  is  inexperienced. 

Where  the  after  nursing  promises  to  be  inefficient. 

Preliininary  medication  is  indicated. — In  nitrous  oxide 
oxygen,  and  nitrous  ether  anaesthesia. 

In  athletic  and  alcoholic  individuals. 

For  neck  and  throat  cases  in  adults  where  intratracheal 
anaesthesia  is  not  available.  Goitre  cases  and  tonsils  and 
adenoids. 

Whenever  one  wishes  to  reduce  the  amount  of  the  anaes- 
thetic used,  i.e.,  acidosis,  diabetes,  etc. 

Where  the  patient  is  neurotic  or  hysterical,  for  psychic 
reasons. 

When  the  post-operative  pain  promises  to  be  extreme ; 
burns,  rectal  cases. 

In  all  local  anaesthesia. 

In  morphine  habitues. 


CHAPTER  XV 

THE  POST-OPERATIVE  TREATMENT  OF  THE 

PATIENT 

THE  DUTIES  OF  THE  NURSE  BEFORE,  DURING  AND 
AFTER  ANESTHESIA 

We  can  scarcely  overestimate  the  influence  for  good 
which  the  nurse  may  exercise  upon  the  jjatient  awaiting 
operation.  A  woman,  especiall}^  leans  very  heavily  upon 
those  about  her  for  sympathy  in  this,  her  time  of  need.  A 
nurse,  who  cannot  enter  somewhat  into  the  patient's  point 
of  view,  will  entirely  fail  in  the  good  which  she  may  do. 
A  patient,  who  is  rated  in  the  nurse's  mind  as  simply  a 
kidney  case,  a  neck  case  or  some  other  kind  of  a  case,  will 
not  fail  to  feel  the  situation  keenly.  As  a  result,  she  will 
feel  the  necessity  of  ]3rotecting  herself  against  evils,  vague 
reports  of  which  have  reached  her  before  she  entered  the 
hospital.  This  spirit  of  distrust  or  apprehension,  even 
though  having  no  foundation,  will  be  very  real  to  the 
patient.  Her  confidence  nmst  be  secured,  she  must  freely 
and  willingly  relinquish  herself  into  the  hands  of  those  who 
offer  her  relief.  We  all  like  to  hear  that  we  have  ens-affed 
the  best  surgeon,  or  the  kindest  and  most  careful  anaesthe- 
tist in  the  citj%  and  while  we  may  be  glad  to  hear  that  our 
case  is  unusual,  it  is  even  better  news  to  learn  that  it  is 
well  within  the  skill  of  the  surgeon,  whom  we  have  engaged. 

The  nurse  should  never  permit  the  suspicion  of  failure, 
or  the  shadow  of  death,  which  may  lurk  in  a  neighboring 
room,  to  enter  the  mind  of  her  patient ;  and  by  her  patient, 
we  do  not  limit  ourselves  to  the  private  case,  but  we  wish 
to  emphasize  more  particularly  the  needs  of  the  case  in 

285 


286 


ANAESTHESIA 


the  ward.  For  those  who  wish  to  enter  into  the  point  of 
view  of  the  patient,  we  have  prepared  a  chapter  which 
appears  at  the  end  of  this  volume. 

The  nurse  should  inquire  into  the  history  of  the  patient, 
more  particularly  in  regard  to  her  previous  anaesthesias  and 


Fig.    121. — Nurse  grasping  patient's  wrists. 

her  reaction  to  morphine  and  other  drugs.  The  condition 
of  the  teeth  should  always  be  inquired  into,  and  false  teeth 
should  be  removed.  She  should  become  perfectly  familiar 
with  the  various  table  positions  necessary  for  the  best 
operative  exposure;  i.e.,  Trendelenburg,  Simms,  lithotomy, 
etc.    (see  page   37).     If  the   operation  is  to  be   in  the 


POST-OPERATIV  E  TREATMENT  OF  PATIENT         287 

patient's  home,  the  patient  lying  in  her  own  bed,  the  nurse 
should  realize  the  ini^^ortance  of  the  amesthetist's  control 
of  the  head  (see  j^age  23).  Once  the  amysthetist  has 
taken  charge  of  the  patient,  it  is  best  that  the  nurse  confine 
her  conversation  with  the  patient  to  as  few  words  as 
possible. 

During  the  course  of  the  anaesthesia,  it  is  always  best 
for  the  nurse  to  refrain  from  all  remarks  as  soon  as  the 
induction  has  begun.  Desultory  conversation  heard  by 
the  patient  is  likely  to  make  her  feel  that  she  is  not  receiv- 
ing the  proper  attention.  Af  this  time  hearing  is  par- 
ticularly acute.  (It  is  bad  taste  for  the  nurse  to  assume 
the  responsibility  of  the  patient's  welfare  until  the  latter 
has  lost  the  sense  of  hearing.) 

If  the  patient  begins  to  struggle,  throwing  the  arms 
above  the  head,  the  nurse  should  grasp  the  wrists,  never 
the  hands  (Fig.  121).  If  she  clasps  the  hands,  as  is  fre- 
quently done,  the  patient  is  very  likely  to  crush  her  fingers 
in  a  vicelike  grip,  or  to  dig  the  finger  nails  into  her  palms. 
Struggling  movements,  unless  they  interfere  with  the 
anaesthetist,  should  be  guided  rather  than  repressed.  By 
such  treatment  they  will  subside  much  more  quickly. 

The  nurse  should  be  constantly  awake  to  the  needs  of 
the  anaesthetist  and  remain  in  sight  as  much  as  possible. 
The  anaesthetist  often  dislikes  to  call  for  ether,  towels,  etc., 
as  this  has  a  tendency  to  upset  the  surgeon,  who  thinks 
something  serious  has  gone  wrong. 

THE   DUTIES   OF  THE   NURSE   AFTER   ANESTHESIA 

Strictly  speaking,  the  nurse  takes  part  in  the  anes- 
thesia inasmuch  as  she  usually  has  charge  of  the  patient 
before  the  stage  of  recovery  has  finished.     Slie  should  be 


288  ANiESTHESIA 

very  familiar  with  the  duties  incumbent  upon  her  during 
this  interval  between  the  return  of  the  reflexes  and  the 
return  of  consciousness.  At  this  time  she  is  likely  to  meet 
with  the  following  difficulties:  Vomiting,  cyanosis,  respira- 
tory failure,  hemorrhage,  circulatory  shock,  hysteria  and 
protracted  unconsciousness. 

VoMiTiXG. — Without  doubt  the  most  common  difficulty 
which  the  nurse  will  meet  is  vomiting.  There  are  at  least 
three  kinds  of  vomiting,  which  may  be  recognized :  Vomit- 
ing, caused  by  ether,  reflex  vomiting  from  the  intra-abdomi- 
nal manipulations,  which  have  taken  place,  and  vomiting 
due  to  morphine. 

The  vomiting  which  is  due  to  ether  usually  begins 
before  consciousness  has  fully  returned,  and  lasts  for  hours 
and  even  days.  This  form  of  vomiting  is  usually  accom- 
panied by  nausea.  Patients,  who  complain  of  the  odor  of 
the  ether,  and  who  frequently  vomit  after  operation,  often 
do  so  because  of  the  odor  of  the  ether  in  their  own  expira- 
tions. This  type  of  case  will  often  experience  marked 
relief,  if  permitted  to  smell  of  some  strong  perfume, 
essence  of  orange,  or  vinegar  applied  by  means  of  a  gauze 
sponge  laid  over  the  upper  lip  (p.  80) .  This  treatment  is 
so  simple  that  it  should  be  applied,  as  a  routine,  to  every 
case  recovering  from  amesthesia.  Those  cases,  which  suff'er 
from  persistent  vomiting,  are  often  relieved  by  having  the 
stomach  washed  out  with  a  warm,  alkaline  solution.  They 
are  usualh^  intolerant  of  fluids  by  mouth,  but  they  will 
often  retain  champagne  or  ginger  ale. 

Vomiting  caused  by  reflexed  pain  is  quite  common, 
especially  where  ovarian  work  has  been  done.  Any  manip- 
ulation, however,  involving  the  parietal  peritoneum  is 
likely  to  be  followed  by  this  form  of  disturbance.     The  use 


POST-OPERATIVE  TREATMENT  OF  PATIENT       289 

of  novocaine,  quinine  and  urea  as  a  nerve  block  during 
the  course  of  the  operation  will  do  much  to  control  this 
type  of  vomiting.  Pre-anjesthetic  narcotics  are  also  val- 
uable in  that  they  reduce  the  sensitiveness  to  pain.  A\Tien 
vomiting  takes  place  as  a  result  of  reflex  irritation,  the 
patient  does  not  complain  of  the  odor  of  the  ether,  as  is 
usually  the  case  in  the  former  type. 

Vomitina-,  which  occurs  as  the  result  of  the  administra- 
tion  of  morphine,  is  quite  frequent,  j^articularly  where  the 
anaesthetic  is  gas  oxygen.  This  type  of  vomiting  is  usu- 
ally unaccompanied  by  nausea.  It  resembles  somewhat 
that  which  is  seen  in  cerebral  irritation,  or  that  which  may 
be  induced  by  apomorphine.  This  form  of  vomiting  is 
the  least  annoying  to  the  patient.  The  author  recalls  a 
case  in  which  the  patient,  in  the  midst  of  such  an  attack, 
remarked  that  "  she  did  not  mind  this,"  that  it  was  nothing 
like  the  vomiting  that  she  had  experienced  after  ether. 

In  order  to  ascertain  the  best  position  in  which  to  place 
a  patient  who  is  vomiting,  the  nurse  should  recall  the  pos- 
ture of  conscious  patients,  who  are  at  liberty  to  place 
themselves  to  the  best  advantage.  Such  patients,  it  will 
be  recalled,  look  directly  forward,  not  to  the  side,  and 
extend  the  head  on  the  neck.  Hence,  when  a  patient,  who 
is  not  yet  conscious,  begins  to  vomit,  he  should  be  placed 
on  his  side.  If  the  head  is  turned  to  the  right,  the  left 
shoulder  be  raised.  The  head  may  be  slightly  extended 
by  supporting  the  brow  with  one  hand.  Patients  recover- 
ing from  operations  on  the  nose  and  throat,  particularly 
children  who  have  had  their  tonsils  and  adenoids  removed, 
should  be  placed  in  the  Simms  or  the  prone  position  (see 
page  44,  Fig.  25 ) . 

Cyanosis. — Cyanosis  is  almost  always  due  to  some 

19 


290  ANAESTHESIA 

form  of  respiratory  obstruction.  It  is  ordinarily  brought 
about  by  one  of  two  causes ;  masseteric  spasm  or  vomiting. 

Masseteric  spasm  often  occurs  in  alcoholic  and  full- 
blooded  individuals.  In  these  cases  the  tongue  becomes 
clenched  between  the  teeth  and  efficiently  blocks  respiration 
through  the  mouth.  If  to  this  condition  there  is  superim- 
posed a  partial  or  complete  nasal  obstruction,  the  condition 
becomes  serious.  A  communication  must  be  established 
between  the  pharynx  and  the  outside  air.  If  the  teeth 
cannot  be  readily  separated  by  the  handle  of  a  spoon  or  by 
the  wedge  (Fig.  13)  (one  of  which  should  be  the  property 
of  every  nurse) ,  then  a  catheter  should  be  slipped  into  each 
of  the  nostrils  for  a  distance  of  about  six  inches.  A  small 
size  rectal  tube  may  also  be  used.  These  tubes  before 
introduction  should  be  lubricated  by  the  saliva,  which  is 
running  out  of  the  patient's  mouth.  Needless  to  say  the 
responsibility  of  such  a  complication  should  be  shared  with 
the  surgeon,  if  the  latter  is  within  ready  call.  Experience 
alone  will  provide  the  confidence  necessary  in  dealing  with 
such  cases. 

Cyanosis  due  to  obstruction  incidental  to  vomiting  usu- 
ally occurs  in  the  first  period  of  recovery.  When  the 
reflexes  have  fully  returned  there  is  much  less  likelihood 
of  this  difficulty.  Cases  of  intestinal  obstruction,  tonsils 
and  adenoids,  or  gastro-enterotomies  are  most  likely  to 
suffer  from  this  complication.  The  treatment  consists  of 
extending  the  head  and  wiping  the  vomitus  from  the  mouth 
and  pharynx. 

During  the  stage  of  recovery  the  patient  lies  flat  in  bed, 
no  pillows  being  employed.  When  consciousness  returns, 
and  vomiting  has  ceased,  elevation  of  the  head  by  one  or 
more  pillows  is  grateful  to  the  patient. 

Cyanosis  occurring  with  dyspnoea  would   suggest  a 


POST-OPERATIVE  TREATMENT  OF  PATIENT       291 

cardiac  lesion,  or  possibly  a  pulmonary  embolus.  In  view 
of  such  a  complication  the  surgeon  should  inmiediately  be 
called. 

Respiratory  Failure. — Where  morphine  is  used  as 
a  preliminary  to  anaesthesia,  particularly  when  the  open 
drop  method  with  ether  is  employed,  the  patient  may  suf- 
fer from  respiratory  depression.  In  this  case  the  respira- 
tions become  shallow  and  very  slow,  A  nurse  who  sees 
this  phenomenon  for  the  first  time  may  become  very  much 
frightened,  as  the  respirations  drop  from  18  down  to  6  or 
8  per  minute.  If  the  patient  is  conscious  he  should  be 
roused  by  conversation.  Instead  of  making  every  effort 
to  increase  the  air  he  breathes,  he  should  be  made  to  breathe 
for  short  j^eriods  into  a  towel,  or  a  rubber  bathing  cap. 
Such  rebreathing  will  stimulate  the  respiration  b}^  virtue 
of  the  accumulated  carbon  dioxide  (see  page  300).  The 
rebreathing  should  not  be  carried  to  a  degree  of  duskiness 
or  cyanosis.  If  oxygen  is  convenient  much  more  satis- 
factory results  may  be  had,  as  the  rebreathing  may  then 
be  protracted.  The  oxygen  may  be  conveniently  bul)bled 
under  the  oiled  silJx  cap  into  which  the  patient  is  made  to 
rebreathe.  Such  cases  often  improve  when  given  a  hypo- 
dermic of  atropine  grs.  1/150. 

Hemorrhage. — Hemorrhage  becomes  evident  in  a 
small,  rapid,  running,  thready  pulse.  Pallor  is  usually 
present  and  the  forehead  is  covered  with  a  cold  perspira- 
tion. When  this  condition  has  begun  in  the  operating 
room  instructions  are  usually  received  to  raise  the  foot  of 
the  bed  (Shock  position,  see  Fig.  123),  as  soon  as  the 
patient  is  returned  to  her  room.  This  position  improves 
the  cerebral  circulation.  A  Murj^hy  drip  or  hypodermoc- 
lysis  (fluid  under  the  breasts)  is  often  employed.  If  the 
condition  is  very  pronounced  air  hunger  will  manifest 


ANAESTHESIA 


itself,  the  respiration  becoming  irregular,  deep  and  sigh- 
ing.   Such  a  case  is  usually  in  desperate  straits. 

Circulatory  Shock. — Circulatory  shock  is  primarily 
a  nervous  phenomenon.  It  may  be  likened  to  syncope  or 
fainting,  carried  to  an  extreme  degree.  The  treatment 
consists  in  keeping  the  head  low  (Fig.  123) ,  applying  heat 
to  the  trunk  and  extremities,  and  in  giving  strychnine 


Fig.   122. — The  Fowler  pcsition.     The  head  of  the  bed  elevated. 

hypodermically.     Enemas    of   hot    coffee    or    coffee    and 
brandy  (2  Oz.)  are  efficient. 

Hysteria. — Where,  by  virtue  of  improper  preliminary 
treatment,  the  induction  has  been  stormy,  it  is  not  unusual 
to  find  an  equally  stormy  recovery.  Neurotic,  hysterical 
women,  particularly  if  addicted  to  alcohol  or  drugs,  may 
give  a  great  deal  of  trouble.  Every  case  must  be  individ- 
ualized.    Such  patients  often  bear  large  doses  of  morphine 


POST-OPERATIVE  TREATMENT  OF  PATIENT       293 

well  and  can  })e  quieted  only  by  this  means.  Of  greater 
importance,  however,  than  the  mere  annoj'ance  caused  by 
such  a  condition  are  the  suicidal  tendencies  which  may  sud- 
denly appear  in  such  patients.  How  many  of  such  have 
escaped  the  vigilance  of  the  nurse  and  flung  themselves 
from  the  nearest  window  to  the  courtyard  below!  While 
such  extremes  are  uncommon,  the  possibility  of  a  calamity 
of  this  nature  should  alwavs  be  borne  in  mind. 


Fig.  123. — The  Shock  position.     The  foot  of  the  bed  elevated. 

Protracted  Unconsciousness. — We  may  presume 
that  a  patient  who  comes  from  the  operating  room  without 
having  vomited  since  the  conclusion  of  the  operation,  whose 
eyelids  are  separated,  eyeballs  fixed,  and  whose  lower  jaw 
offers  no  resistance  when  we  open  and  close  it,  will  not 
recover  consciousness  for  some  time.  If  the  administra- 
tion of  the  anccsthetic  has  been  such  as  to  permit  of  an 
accumulation  of  the  drug  employed,  i.e.,  by  the  rectal 


294  ANESTHESIA 

method;  the  recovery  will  be  much  retarded.  The  use  of 
morphine  and  scopolamine,  or  of  morphine  alone,  often 
causes  the  patient  to  fall  into  a  deep  sleep  after  the  reflexes 
have  returned.  If  left  alone  they  may  sleep  for  four  or  five 
hours.  This  sleep  can  scarcely  be  ascribed  to  an  uncon- 
sciousness from  the  anaesthetic.  The  return  of  consciousness 
should  date  from  the  moment  the  patient  is  capable  of 
answering  questions  rationally.  Unless  roused,  a  patient, 
though  fully  conscious,  will  often  dose  with  his  eyes  closed. 

If  the  respiration,  color  and  pulse  be  satisfactory,  it  is 
of  little  advantage  to  awaken  the  patient.  If  conscious 
motion  or  speech  do  not  return  after  two  or  three  hours, 
however,  effort  should  be  made  to  rouse  him.  A  patient 
who  is  a  diabetic  may  never  recover  consciousness. 

The  relative  rate  of  recovery  by  different  methods  of 
an^esthetization  is  shown  below: 

Gas  oxygen.     Most  rapid  recovery. 

Gas  oxygen  ether. 

Gas  oxygen  ether  and  morphine  and  scopolamine. 

Incomplete  anesthesia  by  ether  or  chloroform. 

Complete  anaesthesia  with  ether  by  the  closed  method. 

Complete  angesthesia  with  ether  by  the  open  method. 

Complete  anaesthesia  with  ether  by  the  closed  method 
with  morphine. 

Complete  anaesthesia  with  ether  by  the  open  method 
with  morphine. 

Complete  anaesthesia  with  ether  by  the  open  method 
with  morphine  and  scopolamine. 

Rectal  anaesthesia — slowest  recovery. 

While  this  table  is  subject  to  many  influences,  it  may 
be  used  as  a  working  basis  to  determine  the  time  at  which 
we  may  expect  consciousness  to  return. 


POST-OPERATIVE  TREATMENT  OF  PATIENT      295 

It  is  scarcely  necessary  to  speak  of  the  necessity  of 
guarding  against  burns  by  hot  water  bags.  As  this  mis- 
hap continues  to  occur,  however,  the  warning  can  hardly 
be  overemphasized. 

As  soon  as  convenient,  after  the  patient  is  placed  in  bed, 
the  room  should  be  darkened  and  all  unnecessary  noise 
incidental  to  arranging  furniture  and  utensils  should  cease. 

Great  care  should  be  taken  to  see  that  the  patient  is 
not  exposed  to  a  draught.  Exposure  at  this  time  may  be 
followed  by  pneumonia  or  pleurisy. 

Stout,  elderly  people,  who  have  suffered  gall-bladder 
operations,  are  prone  to  develop  congestion  of  the  base 
of  the  right  lung  because  of  the  restricted  respiratory 
movements  due  to  pain  in  this  region. 

Goitre  cases,  in  fact  any  neck  case,  should  have  the 
head  elevated  as  soon  as  possible.  This  reduces  the  con- 
gestion of  the  part  and  allows  greater  freedom  of  the 
respiration. 

The  diet  is  ordinarily  ordered  by  the  surgeon  in  charge. 
The  rapidity  of  the  return  of  consciousness  and  the  free- 
dom from  nausea  and  vomiting  usually  indicate  the  toler- 
ance for  liquids  and  food.  Ordinarily  the  first  fluid  given 
is  champagne,  ginger  ale,  albumen  water  or  small  quanti- 
ties of  ice-water.  Cracked  ice  will  sometimes  be  retained 
when  all  else  is  rejected.  Thin  soups,  eggnogs  and  small 
quantities  of  toast  may  follow  in  the  course  of  twenty-four 
hours.  At  the  end  of  another  day  a  soft  diet  may  be  given. 
In  a  general  way  we  may  say  that  the  sooner  food  is 
tolerated,  the  more  rapid  will  be  the  convalescence. 

Patients,  who  are  anaesthetized  by  nitrous  oxide  and 
oxygen  in  the  morning,  are  so  little  affected  that  they  often 
eat  their  regular  meal  in  the  evening. 


CHAPTER  XVI 
CARBON  DIOXIDE  AND  REBREATHING 

It  is  now  quite  generally  accepted  that  the  air  which 
we  exhale  is  not  poisonous,  that  the  organic  matter  which 
it  contains  amounts  to  practically  nothing,  and  that  the 
disagreeable  sensations  experienced  in  ill  ventilated  rooms 
are  primarily  due  to  increased  temperature,  moisture  and 
by-products  of  perspiration.  Exhaled  carbon  dioxide, 
accumulating  under  such  circumstances,  produces  no  un- 
pleasant effects  until  it  has  become  sufficiently  concen- 
trated to  stimulate  the  respiration  to  greater  frequency 
than  normal.  This  stimulating  effect  takes  place  when  the 
concentration  has  reached  4  per  cent.  If  the  amount  be 
further  increased  to  10  per  cent,  distress  and  dyspnoea  is 
experienced. 

These  findings  become  of  great  practical  interest  when 
applied  to  the  individual  who  rebreathes  his  expirations 
from  a  bag.  The  effect  of  such  rebreathing  is  practically 
limited  to  the  accumulated  COo  inhaled  by  the  patient. 

To  some  the  very  idea  of  rebreathing  one's  own  expira- 
tions is  repellent.  Such  esthetic  objections  may  be  met 
by  the  fact  that  ordinary  respirations  into  the  atmosphere 
are  largely  made  up  of  gases  rebreathed.  With  the  ordi- 
nary, quiet  inspiration  only  about  500  c.c.  out  of  the 
total  lung  (vital)  capacity  of  3700  c.c.  is  fresh  air.  As  a 
matter  of  fact  then  we  rebreathe  more  than  six-sevenths  of 
the  air  which  we  use  for  respiratory  purposes  during  quiet, 
unobstructed  breathing.     The  matter  of  rebreathing  into 

296 


CARBON  DIOXIDE  AND  RE  BREATHING  297 

a  bag  becomes  one  of  relative,  rather  than  absolute 
difference. 

The  untoward  effects  of  COo  depend  very  largely  upon 
the  presence  or  absence  of  oxygen.  Many  of  the  evil 
effects  ascribed  to  CO2  per  se  may  be  traced  to  a  deficiency 
of  oxygen.  While  high  percentages  of  CO2,  8  to  10  per 
cent,  probably  cause  bad  effects,  even  in  the  presence  of 
sufficient  oxygen,  such  effects  by  smaller  amounts  under 
similar  conditions  are  open  to  question.  The  physiology 
of  carbon  dioxide  has  assumed  such  proportions  that  we 
can  scarcely  do  more  than  indicate  a  few  of  the  recent 
findings  which  apply  to  anaesthesia. 

Chemistry  of  Carbon  Dioxide. — Carbon  dioxide  or 
carbonic  acid  gas  is  a  colorless,  suffocating  gas,  very  solu- 
ble in  water.  It  neither  burns  nor  does  it  support  combus- 
tion. When  heated  at  high  temperatures  it  breaks  down 
into  CO  and  O.  Ordinarily  it  is  a  very  staple  compound. 
The  atmospheric  CO2  is  derived  from  the  respiration  of 
animals,  combustion,  fermentation,  volcanic  sources,  manu- 
facturing processes  (cement  works,  etc.)  and  from  mines 
after  explosions  of  fire  damp. 

The  origin  of  carbon  dioxide  and  the  condition  in  tvhich 
it  occurs  in  the  blood. — One  of  the  chief  sources  of  carbon 
dioxide  is  muscular  action;  the  general  body  metabolism 
furnishes  the  remainder. 

Carbon  dioxide  is  distributed  uniformly  throughout  the 
mass  of  blood.  Part  is  in  simple  solution,  part  is  in  chemi- 
cal combination  with  the  plasma,  part  is  in  chemical  com- 
l)ination  with  the  corpuscles. 

The  carbon  dioxide  forms  compounds  with  the  alkaline 
bases  in  the  blood,  Na.  K.,  etc.  One  of  the  most  common 
compounds  is  that  formed  with  sodium.     When  the  tension 


298  ANAESTHESIA 

of  the  carbon  dioxide  is  increased,  as  in  the  active  tissues, 
the  equiHbriuni  is  disturbed  and  alkah  is  taken  from  the 
proteids  and  combines  with  the  excess  of  COi-  to  form 
sodium  bicarbonate.  When  the  carbon  dioxide  pressure  is 
reduced,  as  in  the  hmgs,  sodium  bicarbonate  dissociates  in 
part,  giving  off  CO2. 

Oxygen  gas  and  carbon  dioxide  gas  are  as  independent 
of  one  another  as  are  carbon  dioxide  and  nitrogen.  They 
coexist  in  the  same  blood  corpuscle  without  reaction  of 
any  kind.  Hccmoglobin  nearly  saturated  v/ith  oxygen 
will  take  up  carbon  dioxide  as  though  it  held  no  oxygen  in 
combination.  It  is  thought  that  the  oxygen  unites  with 
the  pigment  portion,  and  carbon  dioxide  with  the  proteid 
portion  of  the  haemoglobin.  While  the  amount  of  oxygen, 
which  the  haemoglobin  contains,  does  not  influence  its 
absorption  of  CO2,  yet  the  presence  of  carbon  dioxide 
loosens,  as  it  were,  the  combination  bettveen  the  oxygen  and 
the  hcemoglobin,  allowing  the  latter  to  flow  to  the  tissues 
inore  readily.  This  tendency  of  the  carbon  dioxide  to 
facilitate  the  liberation  of  oxygen  may  serve  to  throw  light 
on  the  hitherto  inexplicable  fact  that  re})reathing  is  often 
of  distinct  clinical  benefit  to  the  anaesthetized  patient. 

Cyanosis  and  Carbon  Dioxide. — The  presence  or 
absence  of  cyanosis  has  nothing  to  do  with  the  amount  of 
carbon  dioxide  present  in  the  blood.  As  has  been  stated 
above,  carbon  dioxide  exists  in  the  blood  in  the  simple 
solution  and  in  chemical  combination  with  alkalies  present. 
The  blood  depends  upon  the  corpuscles  for  its  color  and 
these,  as  is  well  known,  depend  upon  the  amount  of  haemo- 
globin which  is  contained  in  the  individual  cell.  The 
hEemoglobin  then  is  the  element  which  controls  the  color  in 


CARBON  DIOXIDE  AND  REBREATHLXCi  299 

the  blood.  When  the  ha?moglobin  is  exposed  to  oxygen, 
oxyhjenioglobin  is  formed.  It  is  this  compound  that  gives 
the  blood  its  eharacteristic  crimson  hue.  The  color  of  the 
blood  then  depends  entirely  upon  the  amount  of  oxyhjcmo- 
globin  present.  In  the  patient  a  reduction  of  this  com- 
pound results  in  duskiness,  a  greater  reduction  in  blueness 
or  lividity. 

Clinically  one  may  cause  a  patient  to  rebreathe  into  a 
bag  of  oxygen  until  the  carbon  dioxide  is  so  much  increased 
as  to  cause  severe  dyspnoea;  cyanosis,  however,  will  not 
supervene. 

The  Ej^fect  ox  the  Respiration  of  Reducixg  Car- 
box  Dioxide  axd  of  Ixcreasixg  Carbox  Dioxide  ix 
THE  Conscious  Subject. — Defitiitioii  of  Terms. — Apnoea: 
A  condition  of  no  breathing.  Acapnia:  A  condition  of 
diminished  CO2  in  the  blood,  the  cause  of  true  apnoea. 
Dyspnoea:  A  condition  of  increased  breathing.  Hyper- 
capnia:  A  condition  of  increased  CO2  in  the  blood,  often 
the  cause  of  dyspncea. 

The  Effect  of  Reducixg  the  Amouxt  of  CO2  in 
THE  Blood. — Rapid,  deep  breathing  in  the  conscious  in- 
dividual is  often  followed  by  a  sense  of  lightness  in  the 
head.  This  gives  rise  to  a  condition  of  acapnia,  which, 
if  continued,  results  in  apnoea  of  varying  degrees.  In 
everyday  life  this  experience  is  familiar  to  those  who,  uj^on 
going  out  of  doors  upon  a  clear,  exhilarating,  winter's  day, 
breathe  deeply  ten  or  fifteen  times  and  find  their  heads 
swimming  at  the  end  of  this  exercise.  After  having  run 
some  distance  to  catch  a  train,  one  often  experiences  the 
necessity  of  voluntary  respirations  for  some  moments  fol- 
lowing the  exertion.  In  this  latter  case,  oxygen  in  abun- 
dance has  been  supplied  by  the  increased  rate  and  depth 


300  ANAESTHESIA 

of  the  respiration,  but  the  usual  amount  of  CO2  present 
has  been  reduced  and  one  unconsciously  feels  that  if  the 
rate  and  depth  of  the  respirations  can  be  somewhat  les- 
sened, that  the  distress  following  upon  the  exertion  will 
more  quickly  pass  away. 

The  Effect  of  Increasing  the  Carbon  Dioxide  in 
THE  Blood. — The  effect  of  increasing  the  amount  of  car- 
bon dioxide  in  the  blood  is  seen  in  the  simple  experiment  of 
holding  one's  breath.  If  at  some  indefinite  time,  in  the 
course  of  a  normal  respiration,  the  breath  is  held,  the  neces- 
sity to  breathe  will  appear  at  the  end  of  half  a  minute  or 
less;  if,  however,  the  carbon  dioxide  be  well  rinsed  out  of 
the  lungs  by  several  deep  respirations,  the  necessity  to 
breathe  may  be  postponed  for  double  this  time.  The 
absence  of  oxygen  and  the  collapse  of  the  lung  per  se 
stimulate  the  act  of  respiration,  but  these  elements  may  be 
eliminated  in  the  following  experiment:  If  one  fills  a  small 
(one  gallon)  bag  with  pure  oxygen  gas  and,  after  rebreath- 
ing  several  times  into  this,  holds  the  breath  at  the  end  of 
an  inspiration  (lung  distended,  surj^lus  of  oxygen  pres- 
ent), and  takes  the  length  of  time  during  which  it  is 
possible  to  hold  the  breath,  he  will  find  that  this  time  will 
be  considerably  less  than  the  period  of  apncea  possible  if 
he  inhales  pure  oxygen  and  exhales  into  the  atmosphere 
holding  his  breath  at  the  end  of  a  series  of  forced  inspira- 
tions. In  the  second  case,  the  conditions  are  identical 
except  that  the  amount  of  carbon  dioxide  in  the  circula- 
tion is  reduced.  By  carrying  out  this  technic,  disposing 
of  all  possible  CO2  and  filling  the  lungs  with  oxygen,  the 
longest  possible  period  of  apnoea  may  be  obtained,  the 
record  being  (see  page  307)  10  minutes,  10  seconds. 

It  is  possible,  therefore,  by  the  simplest  experiments  to 


CARBON  DIOXIDE  AND  REBREATHE>IG  301 

show  the  effect  of  the  reduction  and  the  increase  of  carbon 
dioxide  in  the  blood  of  the  conscious  subject. 

Where  observations  may  be  made  upon  unconscious 
subjects,  the  effects  are  more  striking  as  there  is  no  inter- 
ference by  the  will. 

The  anjEsthetized  subject  offers  exceptional  opportuni- 
ties to  study  the  phenomena  incidental  to  an  increase  or 
diminution  of  carbon  dioxide  in  the  respired  air.  Such 
observations  may  be  made  not  only  by  the  use  of  the  closed 
method  in  which  case  the  results  are  positive,  but  by  the 
open  method  as  well,  in  which  case  the  effects  of  the  absence 
of  the  necessary  CO2  become  apparent. 

Where  the  Open  Method  is  Used. — One  of  the  most 
common  results  of  the  use  of  the  open  method  is  acapnia. 
If  acapnia  becomes  marked,  as  is  sometimes  the  case,  dur- 
ing an  induction  where  there  is  much  excitement,  the 
patient  shouting,  crying  out  or  breathing  rapidly  and 
deeply,  a  definite  period  of  apnoea  may  develop.  The 
beginner,  who  sees  his  patient  stop  breathing  shortly  after 
a  period  of  excitement  in  ether  anaesthesia,  becomes  much 
upset  and  immediately  starts  artificial  respiration.  If  this 
artificial  respiration  is  ineffectual,  as  is  frequently  the  case, 
it  may  not  interfere  with  the  normal  return  of  the  respira- 
tion. If,  however,  it  be  effective,  it  may,  by  increasing  the 
acapnia,  materially  delay  the  return  of  the  normal  respira- 
tion. If  the  patient  stops  breathing  following  a  period  of 
dyspnoea  from  excitement,  in  the  presence  of  normal  color, 
pulse  and  eye  symptoms  showing  a  light  anaesthesia,  ether 
being  the  anaesthetic  and  morphine  having  been  omitted, 
it  is  best  to  leave  the  patient  alone.  He  will  soon  breathe 
of  his  own  accord  even  though  he  be  apnoeic  for  a  full 


302  ANAESTHESIA 

minute  or  more.  This  phenomenon  is  very  common  in 
children. 

Acapnia  during  the  stage  of  maintenance,  the  open 
method  being  used,  is  of  quite  common  occurrence.  Apncea 
at  this  time  however,  is  more  serious,  and  is  often  associated 
with  cold  perspiration  and  circulatory  depression. 

Acapnia  during  the  stage  of  recovery  is  not  seen  as 
frequently  as  during  induction  and  maintenance. 

When  the  open  drop  method  is  used  the  prevailing  ten- 
dency is  apnoea  from  acapnia.  When  the  semi-open  drop 
method  is  employed  this  tendency  is  reduced  in  proportion 
to  the  amount  of  rebreathing  permitted. 

Where  the  Closed  Method  is  Used. — Where  a  strictly 
closed  method  is  employed,  such  as  is  described  on  page 
132,  one  does  not  see  the  apnoea  of  induction  which  is  com- 
mon to  the  open  method,  because  there  is  no  acapnia.  On 
the  contrary  there  is  very  likely  to  be  dyspnoea  from  hj^per- 
capnia.  Where  a  gas  induction  is  employed,  the  gas  pe?^  se 
induces  a  dyspnoea  which  is  superimposed  upon  that  due 
to  hypercapnia.  The  result  is  rapid,  deep  breathing. 
Rapid,  deep  breathing  at  this  particular  time  enables  one 
to  quickly  saturate  the  patient's  blood  with  ether,  in  other 
words  induction  is  quickly  accomplished.  Morphine  by 
depressing  the  respiration  usually  diminishes  this  dyspnoea 
and  frequently  retards  the  induction. 

During  the  stage  of  maintenance,  however,  the  dys- 
pnoea caused  by  the  hypercapnia  nmst  be  controlled.  Un- 
less this  is  done  the  excessive  breathing  is  likely  to  prove 
a  menace  to  satisfactory  abdominal  manipulations.  If  one 
understands  the  cause  of  the  excessive  breathing,  which  the 
patient  experiences,  he  can  easily  adjust  this  difficulty. 
The  control  of  the  respirations  by  reducing  or  increasing 


CARBON  DIOXIDE  AND  REBREATHIXG  303 

the  CO2  by  means  of  rebreathing  is  exceedingly  interest- 
ing. A  patient  who  is  breathing  deeply  and  rapidly  may, 
in  the  face  of  an  upper  abdominal  operation,  be  immedi- 
ately quieted  by  entirely  emptying  the  rebreathing  bag  and 
filling  it  with  oxygen  and  air;  abdominal  rigidity  and 
excessive  movement  of  the  diaphragm  being  at  the  same 
time  reduced  to  the  minimum  by  the  free  use  of  ether. 

During  the  stage  of  recovery,  after  the  removal  of  the 
face  piece  and  rebreathing  bag,  the  respirations  will  usu- 
ally drop  in  rate  and  depth  from  the  absence  of  the  arti- 
ficial CO2  stimulation.  Shallow  breathing  may  follow 
for  a  few  moments.  This  effect  however,  is  not  due  to 
acapnia  but  from  a  reaction  to  over  stimulation  by  the  CO2. 

When  the  closed  method  is  used,  the  prevailing  ten- 
dency is  dyspnoea  from  hypercapnia.  If  this  is  properly 
controlled  it  is  beneficial  in  as  much  as  it  allows  of  more 
rapid  introduction  and  withdrawal  of  the  ether  employed. 
In  other  words  the  condition  of  the  patient  is  more  pliable 
than  where  there  is  a  tendency  to  apnoea  from  acapnia. 

The  tendency  to  dyspnoea  where  the  closed  method  is 
used  increases  the  safety  of  preliminary  medication,  the 
chief  characteristic  of  which  is  depression. 

Where  Nitrous  Oxide  and  Oxygen  is  the  Ancesthetic. — 
AVliere  oxygen  is  added  to  nitrous  oxide  in  a  quantity  suffi- 
cient to  control  asphyxia,  the  dyspnoea  ordinarily  seen 
when  nitrous  oxide  is  used  alone  is  not  apj^arent.  The 
effect  of  rebreathing  in  such  cases  is  much  the  same  as 
with  the  closed  method  of  ether  administration.  Gas  oxy- 
gen being  a  less  depressing  tj^pe  of  anaesthesia,  however, 
the  effects  of  rebreathing  are  even  more  marked. 

Where  a  constant  flow  of  gas  oxygen  is  employed 


304  ANAESTHESIA 

without  rebreathing  (see  page  233),  we  may  expect  to 
see  the  apnoea  characteristic  of  the  open  drop  method.  Gas 
oxygen  anesthesia  with  excessive  rebreathing  becomes 
annoying  by  virtue  of  the  very  deep  respirations  experi- 
enced. The  addition  of  a  prehminary  dose  of  morphine 
reduces  the  sensitiveness  of  the  respiratory  centre  to  stimu- 
lation (CO2)  and,  with  this  type  of  preliminary  medication, 
more  extensive  rebreathing  may  be  permitted. 

The  type  of  case  with  which  we  have  to  deal  determines 
very  largely  the  extent  to  which  rebreathing  may  be  per- 
mitted. A  full-blooded  individual,  who  has  not  received 
preliminary  medication,  will  tolerate  little  rebreathing 
throughout  ana?sthesia.  On  the  other  hand  an  an£emic 
individual,  who  has  been  permitted  to  rebreathe  an  atmos- 
2)here  of  oxj^gen  and  ether,  will  appear  to  be  stimulated 
rather  than  depressed  by  the  experience.  The  author  is 
convinced  that  the  sicker,  the  more  septic  a  patient  is,  the 
more  are  closed  methods  of  administration  indicated.  In 
such  cases  rebreathing  with  oxygen  almost  always  appears 
to  improve  the  general  condition.  The  normal,  vigorous 
individual  at  the  end  of  an  anaesthetic  by  the  closed  method 
is  almost  always  in  a  better  general  condition  than  if  he 
had  suffered  anaesthesia  by  the  open  method.  The  color 
is  invariably  better,  the  pulse  shows  less  depression  and 
the  body  heat  is  retained.  The  beneficial  effect  of  rebreath- 
ing may  be  accounted  for  by  the  fact  that  the  presence  of 
carbon  dioxide  in  the  blood  corpuscles  increases  the  free- 
dom with  which  the  hcemoglobin  parts  with  its  oxygen, 
thus  pro7noting  oxygenation  of  the  vital  tissues. 

The  beneficial  effect  of  rebreathing  carbon  dioxide  and 
oxygen  when  depression  of  the  respiratory  centre  exists, 
has  become  so  generally  accepted  that  makers  of  oxygen 


CARBON  DIOXroE  AND  REBREATHING  305 

gas  supply  a  mixture  of  oxygen  and  carbon  dioxide  (5 
per  cent. )  for  therapeutic  purposes. 

We  regret  that  space  permits  of  but  a  brief  intro- 
duction into  this  most  fascinating  subject  and  refer  the 
interested  reader  to  the  appended  bibliography. 

In  conclusion  we  would  emphasize  the  fact  that  re- 
breathing  is  not  dangerous  to  health  as  was  formerly  sup- 
posed, that  in  ordinary  respiration  we  rebreath  six-sevenths 
of  our  vital  respiratory  capacity,  and  that  rebreathing  into 
a  bag  is  a  matter  of  relative  importance  rather  than  of 
absolute  difference.  We  would  recall  to  mind  the  fact 
that  carbon  dioxide  is  distributed  uniformly  throughout 
the  mass  of  blood  and  that  carbon  dioxide  and  oxygen  exist 
in  the  blood  independently  of  one  another.  We  would 
impress  the  fact  that  carbon  dioxide  is  not  the  cause  of 
cyanosis,  that  it  is  only  occasionally  incidental  to  it,  and 
that  the  color  of  the  blood  is  entirely  due  to  the  amount 
of  oxygen  present.  We  would  recall  to  mind  the  fact  that 
a  reduction  of  CO2  gives  rise  to  a  condition  known  as 
acapnia,  which  may,  if  extreme,  lead  to  apnoea.  On  the 
other  hand  an  increase  of  COo  known  as  hypercapnia  fre- 
quently results  in  more  or  less  dyspnoea.  The  open 
method  is  characterized  by  acapnia  and  apnoea;  the  closed 
method  by  hypercapnia  and  dyspnoea.  Hypercapnia  may 
be  more  easily  controlled  than  acapnia,  is  of  distinct  advan- 
tage in  the  control  of  the  anesthesia,  and  may  often  prove 
beneficial  to  the  patient.  We  would  draw  attention  to  the 
fact  that  rebreathing  is  of  distinct  advantage  where  there 
exists  respiratory  depression  from  the  use  of  morphine, 
and  we  feel  that  the  closed  method  is  the  method  of  choice 
whenever  the  patient  is  critically  ill.  The  advantage  of  the 
closed  method,  and  the  rebreathing  which  it  implies,  may 
20 


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be  explained  by  the  fact  that 
oxyhemoglobin  dissociates  more 
readih'  in  the  presence  of  abun- 
dant carbon  dioxide. 

Experiment  in  Respira- 
tion.— In  the  course  of  some  ex- 
periments in  respiration  bringing 
out  the  theories  advanced  by 
Yandell  Henderson,  an  under- 
graduate student  in  the  Univer- 
sity of  California  JNIedical  School 
held  his  breath  ten  minutes. 

This  was  accomplished  by 
having  the  student  lie  on  a  table, 
with  a  pneumographic  belt  at- 
tached about  his  thorax  and  com- 
municating with  a  kymograph. 

Slow,  deep  inspirations  were 
taken  for  two  minutes:  this 
eliminated  a  good  portion  of  the 
carbon  dioxide  from  the  blood. 
A  breath  of  oxygen  was  then 
taken  and  the  time  marker 
started.  The  tracing  is  here 
shown.  A  slight  relaxation  of 
the  respiratory  muscles  is  indi- 
cated at  two  minutes.  No  desire 
to  breathe  was  experienced  until 
six  minutes  had  elapsed.  The 
belt  having  been  placed  over  the 
diaphragm,  the  pulse  rhythm  was 
shown   throughout.      From   this 


CARBON  DIOXIDE  AND  REBREATHING  307 

time  on,  the  conscious  effort  to  hold  the  breath  increased 
until  an  involuntary  twitching  of  the  abdominal  muscles 
was  quite  apparent ;  but  no  respiration  took  place.  All  the 
time  the  pulse  was  full  and  strong,  the  color  good.  No 
oxygen  want  a^^peared. 

At  the  expiration  of  ten  minutes  some  vertigo  occurred, 
and  the  impulse  to  breathe  having  become  imperative,  the 
first  inspiration  was  taken — ten  minutes  and  ten  seconds 
having  elapsed.  Xo  great  hyperpnoea,  no  weakness,  no 
heart  changes  appeared.  The  student  rose  from  the  table 
and  went  about  his  class  work  (Fig.  124) . 


CHAPTER  XVII 
EMERGENCY  ANiESTHESIA 

For  the  best  results  in  the  administration  of  an  anaes- 
thetic suitable  apparatus  should  be  employed.  Occasion- 
ally, however,  we  find  ourselves  without  our  familiar 
tools  and  are  obliged  to  improvise  others.  If  the 
signs  of  anaesthesia  are  thoroughly  understood,  we  may 
often  successful!}^  surmount  the  difficulty  confronting 
us.  Improvised  apparatus,  however,  instead  of  offering 
the  easiest  means  of  administration,  usually,  by  virtue 
of  their  inefficiency,  make  the  administration  more  difficult. 
In  the  long  run  the  efficient  method  is  the  easiest  and  the 
most  dependable. 

The  hints  which  follow  are  intended  to  apply  only 
when  the  exigencies  of  the  occasion  preclude  the  use  of 
the  proper  apparatus.  Their  successful  application  will 
depend  to  a  very  large  degree  upon  the  mechanical  clever- 
ness of  the  administrator. 

We  will  imagine  ourselves  stranded  in  an  out-of-the- 
way  place  without  our  usual  paraphernalia. 

When  no  Anaesthetic  Agents  are  at  Hand. — 
When  the  usual  anaesthetic  agents  are  not  at  hand,  the 
employment  of  morphine  and  scopolamine  hypodermi- 
cally,  in  repeated  doses  will  be  found  very  valuable.  Hyo- 
scine  and  scopolamine  being  considered  identical,  we  will 
use  these  terms  interchangeably.  The  dose  of  these  drugs 
for  an  adult  is  morphine  gr.  34'  hyoscine  gr.  1/100.  At  the 
end  of  an  hour  the  dose  may  be  repeated.  The  effect  se- 
cured by  two  inj  ections  is  often  sufficient  to  enable  one  to 
308 


EMERGENCY  ANESTHESIA  309 

operate  painlessly.  Where  after  two  doses  the  anaesthesia 
is  not  yet  satisfactory,  the  dose  may  be  repeated.  The 
reflex  pain  whicli  results  from  the  surgical  manipulation 
appears  to  neutralize  to  a  large  degree  the  depressing 
effects  of  these  drugs.  Atropine,  hypodermically,  in 
doses  of  1/100  gr.  and  rebreathing  applied  by  means  of 
towels,  will  help  to  control  respiratory  depression.  The 
method  is  one  of  necessity  not  of  choice. 

Freezing  the  part  (page  249),  pressure  on  nerve 
trunks  (page  250),  and  pressure  producing  ischaemia  of 
the  part  (page  251),  may  be  employed  in  an  emergency. 

Where  no\  ocaine  and  cocaine  are  to  be  had,  the  results 
will  be  limited  only  by  the  skill  of  the  operator.  Cocaine 
is  more  plentiful  than  novocaine  and  it  is  only  because  of 
this  reason  that  its  use  is  suggested.  It  is  about  seven 
times  more  dangerous  and  should  never  be  used  in  a 
maxinmm  dosage  of  more  than  one  grain. 

Where  Ether,  Chloroform  and  Ethyl  Chloride 
ARE  Available. — Any  unopened  container  with  ether, 
chloroform  or  ethyl  chloride  marked  for  ancestliesia  may 
be  considered  safe. 

Ether  which  has  been  exposed  to  the  air  for  some  time 
and  which  may  be  suspected  of  being  unsafe  should  be 
tested  as  follows,  before  being  administered. 

1.  Upon  evaporation  it  should  leave  no  residue. 

2.  Allowed  to  evaporate  spontaneously  there  should 
be  no  perceptible,  foreign  odor  present  when  the  last 
traces  have  disappeared. 

3.  There  should  be  no  change  in  color  on  the  addition 
of  KOH   (color  indicating  the  presence  of  an  aldehyde). 

4.  Ether  should  not  affect  blue  litmus  paper  even  after 
twenty-four  hours'  contact.  ( Indicating  absence  of  acetic 
acid.) 


310  ANAESTHESIA 

5.  There  should  not  be  an  undue  amount  of  water  or 
alcohol  present.  (If  20  c.c.  of  ether  and  20  c.c.  of  water, 
previously  saturated  with  ether,  be  shaken  together  the 
ether  layer  on  separation  should  not  measure  less  than 
19.5  c.c). 

Chloroforin  which  has  been  exposed  to  air  and  light 
should  be  tested  as  follows,  before  being  administered: 

1.  It  should  possess  a  specific  gravity  of  not  more  than 
1.495  and  not  less  than  1.490.  (Lower  specific  gravity 
indicates  an  excess  of  alcohol.) 

2.  It  should  be  perfectly  transparent  and  colorless. 

3.  It  should  be  absolutely  neutral  to  test  paper. 

4.  It  should  possess  an  agreeable  bland  and  non-irritat- 
ing odor. 

5.  When  allowed  to  evaporate  spontaneously  it  should 
leave  no  residue  either  of  water  or  any  substance  possess- 
ing a  strong  smell. 

6.  When  shaken  with  concentrated  sulphuric  acid  no 
brownish  coloration  should  result.  It  should  form  no  pre- 
cipitate with  a  solution  of  silver  nitrate. 

7.  It  should  not  acquire  a  brown  color  when  heated  to 
the  boiling  point  with  caustic  potash. 

Ethyl  chloride  is  not  likely  to  suffer  from  exposure  to 
air  because  of  its  extremely  low  boiling  point  (its  very 
great  tendency  to  vaporize).  It  should  be  neutral  in 
reaction  and  leave  no  residue  when  vaporized. 

The  Administration  of  Ether  by  an  Improvised 
Open  Method. — An  ordinary,  small,  hand  towel  is  folded 
around  the  nose  and  mouth,  leaving  the  latter  free.  Cheese- 
cloth in  eight  or  ten  thicknesses,  or  one  thickness  of  a  bath 
towel,  is  then  laid  over  the  tojD  of  this.  The  drop  bottle  is 
immediately  improvised  by  puncturing  the  centre  of  the 
ether  can  cap  with  a  single  pin  hole.     The  rate  of  flow  of 


EMERGENCY  ANESTHESIA  311 

the  ether  from  this  hole  is  regulated  by  the  tip  of  the  index 
finger. 

If  the  head  and  the  face  are  covered  during  the  course 
of  an  operation  on  the  face,  ether  may  be  sprayed  directly 
on  that  part  of  the  sterile  sheet  over  the  mouth  without 
disturbing  the  asepsis  of  the  field  of  operation.  A  patient 
suffering  an  operation  under  local  ana3sthesia  recently  was 
thus  anaesthetized  by  the  author. 

When  ether  is  given  in  this  improvised  fashion,  we 
nmst  bear  in  mind  the  possibility  and  danger  of  li(juid 
ether  being  allowed  to  find  its  way  into  the  mouth  of  the 
patient. 

The  Administration  of  Ether  by  an  Improvised 
Semi-Open  Method. — The  use  of  the  towel  cone  is  quite 
common  where  the  need  of  a  semi-open  or  closed  method 
is  felt  but  undeveloped.  We  cannot  speak  of  this  method 
as  a  closed  one  because  the  space  devoted  to  rebreathing 
is  so  small  as  to  necessitate  the  entrance  of  atmospheric 
air  about  the  edges  of  the  mask.  Such  a  mask  as  we  are 
about  to  describe  acts  quite  efficiently  as  an  open  and 
semi-open  method. 

The  material  necessary  for  its  construction  consists  of 
a  towel,  a  newspaper,  gauze,  cheesecloth  or  a  few  strips 
of  soft,  woolen  rags. 

The  mask  is  made  as  follows:  Five  sheets  of  ordinary 
newspaper  are  opened  wide  and  laid  on  a  table  or  on  the 
floor.  These  five  sheets  are  then  folded  lengthwise  twice. 
There  is  now  a  strip  of  newspaper  twenty  sheets  thick 
about  six  inches  wide,  and  as  long  as  the  newspaper  is 
when  opened  wide.  This  strip  is  now  laid  on  an  ordinary 
hand  towel  (1  yd.  x  5^  yd.)  lengthwise,  so  that  the  paper 
comes  in  contact  with  the  long,  free  edge  of  the  towel.  If 
the  strip  of  paper  projects  beyond  the  towel,  it  may  be 


312  ANAESTHESIA 

torn  off.  The  paper  may  be  an  inch  or  two  short  without 
effecting  the  result.  A  towel  three  feet  long  and  one  and 
one-half  feet  wide  will  now  be  covered  by  paper  on  one- 
third  of  its  area.  The  paper  and  towel  are  now  grasped 
at  one  end  and  a  fold  of  about  seven  inches  is  made  (Fig. 
125  a  and  h) .  The  towel  is  outside  and  the  paper  inside. 
The  folding  is  continued  until  the  entire  length  of  the 
towel  and  the  paper  is  included.  The  result  is  a  tube  of 
paper  and  towel  (Fig.  125  c) .  The  hand  is  now  thrust 
through  the  tube  thus  formed  (Fig.  125  d),  and  grasps 
the  free  end  of  the  towel  pulling  it  through,  so  as  to  form 
a  lining  for  the  tube  (Fig.  125  e) .  The  roll  (Fig.  125 
/)  is  now  held  between  the  knees  and  the  free  end  is 
drawn  snug.  The  surplus  is  then  turned  down  over  the 
top  of  the  roll  like  a  collar  (Fig.  125  g).  It  will  fit 
snugly,  needs  no  sewing  and  a  single  pin  will  serve  to 
hold  down  the  one  loose  corner. 

Sewed  cones  are  a  nuisance  to  make,  and  because  of 
this,  one  is  sometimes  tempted  to  use  them  twice — a  most 
unpardonable  practice. 

A  strip  of  gauze  is  now  poked  gently  into  the  top  of 
the  cone,  care  being  taken  that  it  does  not  come  in  contact 
with  the  face.  (When  in  doubt  the  cone  should  be  in- 
spected by  turning  it  upside  down.)  Ether  may  now  be 
dropped  or  sprayed  upon  the  gauze  or  cheesecloth.  When 
it  is  desirable  to  increase  the  concentration  of  the  vapor, 
the  flat  of  the  hand  may  be  laid  partly  or  wholly  over  the 
vent.  At  frequent  intervals  the  gauze  should  be  taken 
out  and  shaken,  as  it  soon  becomes  saturated  with  moist- 
ure from  the  exj^irations.  This  inhaler  is  simple,  relia- 
ble and  as  efficient  as  any  semi-open  method  known  to  us. 

Incidentally  we  would  mention  the  towel  cone  sealed 


5"^ 

3    to 


•*JCL 


O    B 


314  ANESTHESIA 

at  one  end,  only  ti  condemn  it  as  asphyxial  and  inefficient. 

The  Use  of  Chloroform  ix  Emergency  Anaesthe- 
sia.— The  use  of  chloroform  in  emergency  anaesthesia 
should  be  strictly  limited  to  the  C.  E.  mixture  (see  page 
194).  It  should  never  be  employed  where  there  is  a  limi- 
tation of  air.  It  should  not  be  used  where  there  is  a  gas 
light  or  other  flame.  Unless  a  proper  mask  is  available, 
the  face  should  be  anointed  with  vaseline  to  prevent  burn- 
ing of  the  skin.  The  use  of  chloroform  in  emergency 
anaesthesia  should  be  limited  to  the  period  of  induction. 
The  physiology  of  chloroform  anaesthesia  (page  185) 
should  be  understood,  and  the  causes  of  death  (page  195) 
should  be  thoughtfully  anticipated. 

Small  quantities  of  chloroform  on  a  gauze  sponge, 
held  before  the  patient  by  means  of  a  sterile  sponge  holder, 
are  sometimes  used  for  operations  about  the  face. 

The  Use  of  Ethyl  Chloride  in  Emergency  Anes- 
thesia.— The  use  of  ethyl  chloride  as  an  emergency  anaes- 
thetic is  suggested  chiefly  as  a  substitute  for  nitrous  oxide. 
We  would  emphasize  the  necessity  of  great  care  in  its  use 
and  recall  to  the  reader's  mind  the  tendency  of  the  patient 
to  collapse,  following  its  use.  It  has  its  place,  neverthe- 
less, and  if  cautiously  used,  will  be  found  quite  serviceable. 

Intrapharyngeal  Anaesthesia  by  Improvised 
Methods. — The  patient  is  anaesthetized  by  the  improvised 
towel  cone.  When  anesthesia  has  been  well  induced,  a 
catheter  or  small  rectal  tube  is  slipped  into  one  of  the 
nostrils.  (If  two  catheters  are  available,  having  a  "  Y" 
tube  connection,  so  much  the  better.)  The  end  of  the 
catheter  is  now  fitted  over  the  bottom  of  a  glass  funnel; 
the  funnel  is  filled  with  gauze;  ether  or  the  C,  E.  mixture 
is  then  cautiously  dropped  upon  this  gauze.     The  vapor 


EMERGENCY  ANAESTHESIA  315 

thus  formed  is  inspired  by  the  patient.  Great  care  must 
he  taken  to  prevent  liquid  ether  from  finding  its  way  into 
the  catheter.  This  may  be  prevented  })y  holdin^>-  the  fun- 
nel on  its  side,  so  that  liquid  ether  will  run  out.  Fig.  126 
shows  the  funnel  packed  with  gauze. 

With  this  method  we  depend  upon  the  amount  of  sue- 


I  :•-■.    ]-■'■.    -lurin--'  with  tube  for  intrapharyngi\il  aiuc-tli'-; 

tion  through  the  tube  brought  about  by  the  respirations 
of  the  patient.  This  being  comparatively  small,  the 
method  by  ether  alone  is  quite  inefficient.  When  the  C.  E. 
mixture  is  used,  better  results  may  be  expected. 

Intratracheal  Ax.^:sthesia  by  Improvised  Appara- 
tus.— Intratracheal  aneesthesia  may  be  satisfactorily  ad- 
ministered by  employing  a  technic  similar  to  that  described 


316 


ANAESTHESIA 


for  the  emergency  intrapharyngeal  method.  When  this 
method  is  employed,  we  introduce  a  tube  directly  into  the 
trachea,  attaching  the  distal  end  to  a  tube  which  connects 
it  to  a  funnel  as  described  above.     This  method  is  much 


Fig.   127. — Funnel  with  tube  for  intratracheal  anaesthesia.     (Courtesy 
American  Journal  of   Surgery.) 

more  efficient  than  the  intrapharyngeal  method,  because 
a  much  larger  volume  of  air  passes  through  the  tube.  An 
apparatus  similar  to  the  one  shown  in  Fig.  127  has  been 
repeatedly  used  with  much  success. 

The  danger  of  such  a  method  in  inexperienced  hands  is 


EMERGENCY  ANAESTHESIA  317 

much  greater  than  that  described  on  page  159,  but  its 
usefulness  where  indicated,  in  the  absence  of  the  usual 
apparatus,  can  hardly  be  denied.  By  such  a  method  it  is 
impossible  to  obtain  positive  intrapulmonary  pressure. 

Accessories  to  Emergency  Anesthesia. — A  mouth 
wedge,  necessary  when  masseteric  spasm  and  cyanosis 
occur,  may  easily  be  im^Jrovised  by  whittling  a  piece  of 
hard  wood  in  the  form  shown  in  Fig.  13. 

A  breathing  tube,  acting  in  the  capacity  of  the  Connell 
thtoat  tube.  Fig.  14,  may  readily  be  made  from  a  five-inch 
piece  of  rectal  tube  or  other  stout  tubing  having  a  diameter 
of  at  least  half  an  inch.  A  safety  pin  should  always  be 
fastened  across  the  outer  end. 

If,  in  the  course  of  an  abdominal  operation,  the  j^ulse 
becomes  small  and  rapid,  indicating  hemorrhage  and  the 
need  of  a  saline  injection,  the  quickest  and  most  convenient 
wa}"  of  administering  this  is  to  pour  hot  saline  directly  into 
the  abdominal  cavity.  While  this  is  being  done,  an  ordi- 
nary fountain  syringe  should  be  filled  with  w-arm  saline, 
and  a  hypodermoclysis  needle  attached  to  the  tubing  lead- 
ing therefrom  should  be  thrust  deep  into  the  loose  tissue 
under  one  of  the  breasts.  The  height  of  the  rubber  bag 
determines  the  rate  of  the  flow.  It  may  be  started  at  three 
feet  above  the  patient  and  raised  if  the  flow^  is  not  suffi- 
ciently rapid.  Hypodermoclysis  is  an  exceedingly  satisfac- 
tory means  of  introducing  saline  solution  into  the  general 
circulation.  The  effects  are  not  so  rapid  and  it  may 
safely  be  started  at  an  earlier  time  than  can  an  intravenous 
injection.  The  greatest  advantage,  however,  lies  in  the 
fact  that  it  does  not  delay  the  course  of  the  operation  by 
requiring  the  attention  of  the  surgeon  or  his  assistant. 
All  the  necessary  details  may  be  cared  for  by  the  nurse, 
working"  under  the  direction  of  the  ana?sthetist. 


CHAPTER  XVIII 
THE  ANESTHETIST'S  RECORDS 

Those  who  administer  anaesthetics  sooner  or  later  find 
it  essential  to  preserve  a  fairly  comprehensive  record  of 
each  case.  This  becomes  necessary  not  alone  from  a  scien- 
tific point  of  view,  but  also  for  self-protection. 

It  is  frequently  inconvenient  to  gather  personal  data  at 
the  time  of  the  operation.  To  avoid  this  embarrassment  a 
record  card  and  a  self-addressed,  stamped  envelope  may  be 


NAME 

DATE  OF  OPERATIONS                                     NO 

AGE                   SEX                      ADDRESS 

NAME  AND  ADDRESS  OF  NURSE 

OPERATIONS 

SURGEON 

ASSISTANTS 

UNCON8CI0USNCS8  AFTCR  OPERATION 

/0'»'L-<-'^             PREVIOUSLY  ANAESTHETIZED     /       ^1.0 

CONOITION  or  EYCS  ArTCP  OPERATION 

Oli                            „CH»B     or  INDUCTION  i^tC*/*-     '/>U>Tt«A*& 

t    TEETH  /  aMr     OUMCsTs     RIQIDITY 

JACwnCTioN   UjiPtrxn   vomitinq  BWfoKi.  0\)tM<a.  ArTER 

ANAI5.  SUCCESS                            S       &^ 

P         <?^                   A       <^^ 

REMARKS 

BILL  sent:  PAjBi 

Fig.   128. — Front  of  anaesthesia  record  card. 


left  with  the  nurse,  who  is  usually  glad  to  secure  the  desired 
information.  The  accompanying  figures  illustrate  such  a 
card. 

The  front  of  the  card  (Fig.  128)  requires  but  little 
comment. 

Char,  of  Induction. — Excitement  absent,  moderate, 
marked. 

Ames.  Success. — S.,  Point  of  view  of  the  surgeon;  P., 
of  patient;  A.,  of  Anaesthetist. 

318 


THE  ANAESTHETIST'S  RECORDS 


319 


Heads  for  data  which  are  absent  should  be  crossed  out. 
On  the  reverse  of  the  card  (Fig.  129)  attention  may  be 
directed  to  the  following  points : 


System  Anaesftiesia 

/?.... 

/y^,^.. 

Apparatus  Ostd 

''.o-t 

3  'va,<n/i 

ETHER 

.      6 

1   o\ 

ff*^ 

^tUiefrCfoRM 

6 

<) 

'1 

M.   &  A. 

A  u 

cvl 

/Ol  i'  ^ 

^nt . 

^JUrtfEN 

^Stiflmlanls 

Respiration 

i  '>  I 

Hi 

C     REFLEX 

iM 

PUPIL 

oL  c     c 

c  (^  oL 

160 

170 

160 

160 

140 

130 

120 

110 

100 

90 

SO 

TO 

60 

BEFORE 

mtSIHESIt 

ANAtSIHfSIA 

BEGUN 

1ST  MR. 
20     40     60 

2NO  HR 
20     40     60 

3R0    HR. 
20    40    60 

coNsaousNBS 

RETURNED 

A.M. 

HJtrr 

A.M. 

P.M. 

< 

(A 

t^ 

sm 

!li< 

n 

tt. 

• 

a 

/■^o 

• 
/Oi'f 

/o.J/» 

TOTAL  TIME  OPERATION           /.  i"<3                       ANAESTHESIA            2.<'0 

ANAESTHESIA  BEFORE   OPERATION               -/d 

Fig.  129. — Reverse  of  anaesthesia  record  card. 


System  of  Ancesthesia. — Open,  closed,  pharyngeal,  in- 
tratracheal, intravenous,  rectal,  etc. 
M.  (§  A. — Morphine  and  atropine. 


320  ANESTHESIA 

Respiration. — Free,  obstructed. 

C.  Refleoc. — Sharp,  dull,  absent. 

Pupil. — Normal,  contracted,  dilated. 

Most  records  are  squared  off  for  five-minute  pulse- 
readings.  To  save  space  twenty -minute  divisions  are  here 
used.  Five-minute  readings  may  be  shown  by  a  dot  one- 
fourth  way  across  the  space.* 

*  Reprinted  modiSed  from  Journal  of  the  American  Medical  Association. 


CHAPTER  XIX 
ASPIRATORS 

The  use  of  aspirators  particularly  for  nose  and  throat 
work,  is  of  interest  to  the  anaesthetist,  as  their  employ- 
ment aids  materially  in  controlling  the  freedom  of  the 
respiration. 

Four  types  of  aspirators  may  be  recognized : 

1.  Where  the  suction  is  produced  by  a  foot  pump. 

2.  Where  the  suction  is  produced  by  water  power. 

3.  Where  the  suction  is  produced  by  electricity. 

4.  Where  the  suction  is  produced  by  steam  power. 
The  foot  pump  method  is  the  most  simple  but  the  least 

efficient  of  the  four  methods.  A  foot  pump  sucker  suita- 
ble for  throat  and  abdominal  work  is  shown  in  Fig.  130. 

Aspiration  by  water  power  is  quite  popular.  The  suc- 
tion which  results  is  constant  and  quite  efficient.  When 
in  use  the  apparatus  is  attached  to  any  convenient  water 
faucet.  The  amount  of  suction  produced  depends  upon 
the  head  of  water  at  command.  If  the  faucet  is  located 
at  the  top  of  the  building  some  difficulty  may  be  experi- 
enced in  securing  sufficient  water  power  to  produce  the 
desired  result.  The  essential  features  of  the  apparatus 
are  shown  in  Fig.  131. 

Aspiration  by  electricity  is  often  used  where  ether 
vapor  is  being  delivered  for  throat  work.  In  this  case  the 
suction  produced  by  the  blower  which  provides  air  to  form 
the  ether  vapor  is  employed.  The  disadvantage  of  this 
particular  arrangement  lies  in  the  fact  that  the  air  used 
to  vaporize  the  ether  is  taken  (by  suction)   from  the  de- 

21  321 


322 


ANAESTHESIA 


Fig.   130. — Foot  aspii  ^la    lirni--  .It  Hospital. 


ASPIRATORS 


323 


oxygenated  and  contaminated  field  of  operation.     The 
noise  of  the  motor  is  often  very  annoying  and  a  satisfac- 

A 


Fio.   131. — Water  aspirator. 


tory  electrical  supply  must  be  near  at  hand.  It  has 
the  advantage,  however,  of  being  very  convenient.  An 
example  of  such  an  apparatus  is  shown  in  Fig.  132. 


3^ 


ANAESTHESIA 


Aspiration  by  steam.  This  type  of  aspiration  is  not 
only  of  value  in  nose  and  throat  work,  but  plays  even  a 
larger  part  in  removing  fluid  from  the  abdomen  and  else- 


f^  G  TIETMANN    &    CO.  NCW     YORK  S^ 


Fig.    132. — Electrical  aspirator. 


where.  The  utilizing  of  steam  for  suction  purposes  is 
brought  about  by  the  employment  of  what  is  known  as  an 
ejector.     This  ejector,  a  cross  section  of  which  is  shown 


Fig.    133. — Ejector  for  steam  aspirator. 


in   Fig.    133,   may   be   purchased   at   any   steam   fitting 
establishment. 

The  steam  in  passing  from  A  through  F  into  G  and 
finally  into  the  discharge  pipe  F  produces  a  partial  vacuum 


ASPIRATORS 


325 


in  the  chamber  enclosing  F  and  G,  which,  being  connected 
to  the  suction  tubing  marked  "  supply,"  performs  the 
intended  work. 

The  steam  supply  pipe  A  may  be  one  which  is  tapped 
at  any  convenient  place  in  the  sterilizing  room  or  else- 


FiG.   134. — The  steam  pump  aspirator  complete  with  aspirating  tongue  depressor, 
Fordham  Hospital. 

where.  The  discharge  pipe  E  may  be  led  into  a  pail  of 
water  or  be  discharged  at  some  point  in  the  basement  or 
out  of  doors. 

Fig.  134  is  a  view  of  the  entire  apparatus  in  question — 
ejector,  tubing,  receiving  bottle  (for  aspirated  material) 
and  aspirating  tongue  depressor. 


326 


ANiESTHESIA 


The  bottle  which  receives  the  discharge  should  have  a 
capacity  of  about  2000  c.c.  The  tubing  between  the  ejec- 
tor and  the  bottle  may  be  of  pressure  hose  or,  better  still, 
flexible  steel  gas  tubing,  as  shown  in  the  illustration.    This 


Fig.    135. — A,  Aspirating  tongue  depressor;  B,  tongue  depressor. 


tubing  should  be  at  least  fourteen  to  eighteen  feet  long. 
If  a  greater  length  is  required  it  is  more  satisfactory  to 
replace  part  of  this  by  permanent  piping  from  the  ejector. 
The  distal  end  of  this  tube  is  soldered  to  a  length  of  brass 
tube  perforating  the  cork  in  the  bottle.     This  cork  must 


ASPIRATORS  327 

be  considerably  larger  than  the  mouth  of  the  bottle,  else  it 
will  be  sucked  in  by  the  powerful  negative  pressure. 

The  tubing  from  the  bottle  to  the  aspirating  tongue 
depressor  is  of  heavy  non-collapsible  rubber,  capable  of 
repeated  sterilization. 

Whatever  may  be  the  source  of  the  suction  produced, 
foot  power,  water,  electrical  or  steam,  the  actual  removal 
of  the  fluid  is  accomplished  by  variously  shaped,  per- 
forated, metal  tubes.  A  common  type  is  shown  accom- 
panying the  electrical  aspirator.  A  tongue  depressor 
which  aspirates,  however,  is  the  ideal.  Fig.  135^  is  the 
aspirator  employed  by  the  author.  It  is  made  to  corre- 
spond as  nearly  as  possible  to  the  shape  and  size  of  a  popu- 
lar tongue  depressor,  shown  in  Fig.  135B,  and  when  in  use 
it  does  away  with  the  necessity  of  employing  an  additional 
instrument,  as  it  acts  in  the  capacity  of  an  efficient  tongue 
depressor  and  aspirator  at  the  same  time. 


CHAPTER  XX 
THE  POINT  OF  VIEW  OF  THE  PATIENT 

Medicine  for  many  of  us  is  the  centre  about  which 
the  world  revolves.  We  see  life  in  its  embryonic  dawn. 
We  follow  it  most  closely  in  its  morbidity  through  adoles- 
cence, maturity  and  decline,  until  at  last  the  spontaneous 
metabolism  is  at  an  end.  Lead  on  by  experimental  curi- 
osity into  the  nature  of  things,  we  do  not  leave  man  here 
but  dissect  him  with  scalpel  and  microscope  to  the  limit  of 
present  day  instruments.  By  electrical  and  chemical 
stimuli  we  effect  a  parody  on  life;  we  make  dead  muscle 
move  again,  and  look  therein  for  the  secret  of  life. 

From  within  the  circle  drawn  by  medicine  we  limit  our 
speculations  as  to  the  great  truths.  We  build  our  theology 
out  of  coarse  stuff  and  wonder  why  the  edifice  is  so  unsatis- 
factory. We  ignore  the  more  delicate  tools  of  logic  and 
philosophy,  which  are  equally  as  truthful  and  more 
penetrating. 

The  medical  man  has  a  tendency  to  relegate  the  intel- 
lectual life  to  the  obscure  environment  of  psychiatry.  The 
intellectual  life  to  him,  broadly  speaking,  is  but  the  reac- 
tion to  environment  and  of  comparatively  small  account 
at  best.  The  distinction  which  he  draws  in  his  own  mind 
between  a  man  and  a  monkey  is  not  very  acute.  While 
not  always  openly  acknowledged,  many  present  day  medi- 
cal men  serve  the  cult  of  materialism.  With  such  a  more 
or  less  well  defined  materialism  they  approach  their 
patients.    Their  patients  are  the  world. 

The  average  layman  has  little  or  none  of  the  physi- 

328 


POINT  OF  VIEW  OP   PATIENT  329 

cian's  detailed  knowledge  and  interest  in  histology  and 
pathology.  He  has  occupied  his  life  in  listening  to  the 
call  of  the  "  ego,"  that  intangible,  intellectual  entity  which 
is  self.  Such  patients  view  medicine,  and  in  viewing  medi- 
cine, judge  us  from  a  point  of  view,  which  it  would  be  well 
for  many  of  us  to  appreciate.  As  a  science  cannot  be 
broadly  judged  from  its  own  plane  but  must  needs  be 
seen  from  without,  so  can  we  best  serve  our  patients  by 
viewing  our  profession  from  without. 

The  wealthy,  by  their  influence,  social  and  financial, 
obtain  through  the  very  atmos^^here  with  which  they  sur- 
round themselves,  a  certain  consideration,  irrespective  of 
our  habitual  personal  mannerisms.  The  deference  paid 
these  by  the  materialistic  man,  by  him  who  cannot  under- 
stand the  spiritual  element,  is  a  deference  to  the  peculiar 
qualities  which  the  former  possess,  their  keen  mentality, 
their  natural  refinement  and  their  wealth,  rather  than  to 
their  deeper  humanity.  His  sympathy  finds  its  reward  in 
inmiediate  common  interests.  On  this  ground  the  materi- 
alist is  fairly  well  remunerated,  but  what  stimulus  has  he 
for  a  charity  for  which  he  can  see  no  reward  ( 

It  is  the  poor  who  send  up  this  cry;  the  poor  in  the 
great  hospitals  and  dispensaries.  Those  from  whom  we 
feel  that  we  tolerate  much  and  who  are  ^perpetually  in  need 
of  help.  They  cannot  reward  us  by  money,  they  cannot, 
and  by  nature  often  will  not,  reward  us  by  sparkling  wit 
or  by  dull  thanks.  If  we  would  be  compensated  we  must 
see  an  image  of  the  Almighty  in  their  presence.  We  must 
feel  the  unspoken  thanks  which  illiteracy  cannot  utter. 
We  nmst  look  beyond  the  colorless  environment  of  the 
hospital  ward  and  see  the  situation  from  their  point  of 
view. 


330  ANAESTHESIA 

Let  us  pass  from  the  narrow  confines  of  their  station 
in  life  and  go  with  them  to  the  great  hospital  with  its 
subtle  wonders,  a  universe  in  itself.  Here  the  house  sur- 
geon wields  a  monarch's  sway.  By  his  orders  we  fast  or 
eat,  we  are  allowed  to  go  about  or  we  are  obliged  to  stay 
abed  all  the  day.  He  controls  the  nurses,  who  have 
power  enough,  goodness  knows,  when  he  is  absent. 

As  for  the  visiting  surgeon,  he  is  a  sort  of  a  deity.  He 
rules  even  the  house  surgeon.  His  will  is  law  and  his 
every  remark  is  treasured  up  to  be  produced  at  intervals 
for  the  benefit  of  a  coterie  of  friends.  Imagine  that  celes- 
tial body,  as  he  moves  about  in  his  orbit  stopping  before 
one  of  these  people.  Imagine  the  pain  inflicted  by  a  curt 
remark,  by  a  rough  manipulation  or  by  a  misapplied  pun, 
forgotten  in  the  saying  perhaps  by  him,  but  treasured 
through  the  long,  uneventful  day  by  the  patient;  imagine 
the  unsatisfied  thirst  for  just  a  little  information  when 
the  sudden  declaration  is  made:  "  We  will  operate  to-mor- 
row at  three." 

To-morrow  dawns  at  last,  but  it  is  a  long  wait  before 
afternoon.  During  the  wait  one  has  nothing  to  eat  and 
is  nervous  with  apprehension.  Three  o'clock  finally 
arrives  but  the  minutes  pass  by  in  suspense  until  it  is 
perhaps  nearly  four;  then  quite  accidentally  a  nurse  may 
think  to  inform  the  patient  that  the  doctor  called  a  few 
hours  ago  to  say  that  he  had  decided  to  postpone  the  opera- 
tion until  the  following  day.  The  operating  staff  had 
been  informed  of  course,  but  no  one  had  remembered  to 
tell  the  patient.  Then  follows  the  sudden  relapse  when 
the  tension  is  released.  The  suspense  is  only  prolonged, 
however,  for  the  next  day  is  to  come.  But  now  the  possi- 
bility of  a  second  delay  enters  in  and  nothing  is  sure  until 


POINT  OF  VIEW  OF  PATIENT  331 

the  stretcher  is  brought  and  the  patient  is  conveyed  to  the 
operating  room. 

The  anaesthetist  is  unconcerned.  From  his  point  of 
view  the  patient  entered  into  his  presence  from  apparent 
obHvion  and  will  leave  him  in  real  oblivion.  Perhaps  it  is 
a  little  woman,  who  trembles  now  and  then;  whose  teeth 
chatter  and  whose  eyes  persist  in  filling  uj)  in  spite  of  her- 
self. If  the  anaesthetist  would  only  see  her  point  of  view, 
he  could  not  refuse  to  comfort  her;  but  instead  of  this,  in 
an  impersonal,  colorless  voice  he  sharply  remarks  "  Here, 
stoj)  that  nonsense.  We  can't  have  any  of  this  fuss."  If 
he  only  knew  how  impossible  it  was  for  the  patient  to 
control  herself  and  how  gladly  she  would  stop  "  that  non- 
sense," if  she  could.  In  an  equally  impersonal  manner 
she  is  told  that  no  one  is  going  to  hurt  her,  or,  what  is 
worse,  the  anaesthetist  may  calmly  putter  for  an  intermina- 
ble time  in  his  preparations  and  when  about  to  start  is 
told  to  wait,  as  the  case  under  operation  is  not  far  enough 
advanced  to  start  the  next  one.  Then  follows  another 
delay  of  perhaps  half  an  hour  in  the  close  etherizing  room 
with  every  minute  threatening  a  climax.  Finally  the 
order  is  given  to  start  the  anesthetic.  Speed  is  essential, 
hence  concentrated  ether,  hence  cough,  suffocation,  stran- 
gling and  a  sense  of  sinking  into  utter  nothingness.  An 
effort  to  free  one's  self,  and  one's  hands  are  pinned  do^vn 
on  one's  breast,  which  pressure  adds  to  the  distress.  Long 
before  consciousness  is  lost  someone  cries  out  "  Soak  it  to 
her,  soak  it  to  her."  These  last  words  echoing  and  re- 
echoing do^vn  the  long  vista  leading  out  of  consciousness. 

This  is  not  intentional  cruelty,  it  is  the  result  of  high 
pressure,  of  system  gone  mad  and  most  of  all  of  the  lack  of 
appreciation  of  the  patient's  point  of  view. 


332  ANESTHESIA 

But  the  reduction  of  the  ego  to  a  greater  or  less  amount 
of  Xissel's  granules  does  not  elevate  one's  views,  it  but  con- 
centrates them.  The  motive  is  analogous  to  that  of  pure 
conservation  of  energy  in  a  machine.  It  does  not  attract 
all.  It  appeals  mostly  to  the  pathologist,  to  the  histolo- 
gist  or  to  the  biologist  and  its  consideration  proceeds  not 
from  a  warm  sympathy  but  from  good  policy. 

There  are  j^ossibihties  in  men  outside  the  limits  of  ions 
and  their  uncounted  subdivisions.  There  are  qualities 
inherent  in  that  hidden  power,  which  is  born  in  the  union 
of  sperm  and  ovum,  predominating  and  directing  cell  divi- 
sion, assigning  each  to  its  delicate  community  task.  It  is 
this  intelligence  which  permits  the  organism  to  adopt  itself 
to  its  peculiar  circumstances  with  the  marvelous  aptitude 
which  we  know  so  well.  It  controls  a  system  of  repair 
and  defense  so  complex  that  we  can  but  theorize  as  to  the 
mode  of  its  action.  As  we  direct  our  attention  to  the 
physiology  and  the  organic  chemistry  of  the  cell,  we  lose 
sight  of  the  larger,  more  amazing  community  life  of  the 
countless  groujDS  of  differentiated  cells,  each  working  along 
independent  lines  for  the  common  good.  These  groups, 
if  not  guided  in  their  ensemble  by  a  central  authority, 
could  never  adajjt  themselves  to  the  vicissitudes  of 
environment. 

One  need  not  follow  the  isms  of  the  faddists  to  be  up 
to  date.  Truth  is  not  a  matter  of  time  or  place,  it  is 
unchangeable.  The  acknowledgment  of  the  existence  of 
the  supernatural  in  the  soul  of  man  is  not  an  evidence  of 
reversion  in  tyjje.  It  is  but  the  result  of  the  acceptance 
and  of  the  intelligent  correlation  of  a  host  of  facts  which 
we  see  about  us. 

Admitting  the  presence  of  a  soul,  and  as  the  logical 


POINT  OF  VIEW  OF  PATIENT  333 

sequence  the  attributes  and  adornments  of  the  soul, 
may  we  not  awaken  and  develop  tlie  loveliest  of  these, 
charity,  seeing  in  man,  however  j^oor  and  illiterate,  the 
seal  of  divinity.  Courtesy  is  honored  when  found  in  such 
company. 

A  man  who  can  see  the  divine,  has  an  incentive  which 
is  impossible  in  the  case  of  the  mere  microscopist.  He  can 
understand  that  charity  is  its  own  reward  and  as  a  con- 
sequence he  offers  it  whenever  possible. 

We  can  therefore,  in  adopting-  the  patient's  point  of 
view,  eliminate  much  pain  and  distress.  The  acceptance 
of  such  a  course  involves  no  expense.  A  moment  of 
thoughtfulness  is  all  that  is  required.  A  word,  a  smile 
or  a  sympathetic  glance  will  do  much  to  lighten  anxiety 
and  pain.  iMorning  operations  when  possible;  avoidance 
of  postponements ;  a  morphine  j^recedence ;  unfailing  cour- 
tesy and  consideration — all  these  may  seem  trifles,  but  in 
reality  are  marks  of  human  kindness. 

In  such  a  measure  as  a  man  spends  his  efforts  in  doing 
good  to  others,  in  just  such  measures  will  he  find  j^eace 
and  contentment  within  himself. 


BIBLIOGRAPHY 

CARBON  DIOXIDE  AND  REBREATHING 

Gatch,  W.  :  Nitrous  Oxide  Oxygen  Aiijesthesia  by  the 

Method    of    Rebreathing,    Journal    A.    M.    A., 

March  5,  1910,  p.  77.5. 
The  Use  of  Rebreathing  in  the  Administration  of 

Ancesthetics,  Nov.  11,  1911,  p.  1593. 
Rovsing:     Abdominal    Surgery,    Clinical    Lectures    for 

Students  and  Physicians.    Translation  by  Pilcher, 

Philadelphia,  191*4. 
Hendeeson- Yandell  :    1.  Am.  Jour.  Physiology,  1909, 

24;  66. 

2.  Acapnia  and   Shock    (seven  papers).  Am.  Jour. 
Physiology,  1908-1913. 

3.  Respiratory   Experiments   on   INIan.      The   Jour. 
A.  M.  A.,  April  11,  1914,  p.  1133. 

4.  Tr.  Am.  Gynec.  Soc,  1914. 

5.  Surg.,  Gynec.  and  Obstetrics,  1914,  p.  386. 

6.  Shock  After  Laparotomy ;  Its  Prevention,  Produc- 
tion and  Relief.    Am.  J.  Physiol.,  1909,  21,  60. 

7.  Fatal   Apnoea   and  the    Shock   Problem.     Johns 
Hopkins  Hospital  Bulletin,  Aug.  1910,  21,  No.  233. 

Barceoft:  Respiratory  Function  of  the  Blood.  Cam- 
bridge, 1914. 

Bryant  and  Henderson:  Closed  Ether  and  a  Color  Sign. 
Jour.  A.  M.  A.,  July  3,  191.5,  p.  1. 

Levi  Ettore:  Studies  on  the  Patho-Physiologic  Action  of 
CO2  and  on  the  Therapeutic  Applications  in  Sur- 
gery and  Medicine  of  Mixture  of  (O)  and  CO2. 
Estr.  d.  rev.  di.  clin.  med.,  1910,  11,  30,  31. 

335 


336  ANAESTHESIA 

Hill  and  Flack:  The  Effect  of  Excess  of  Carbon 
Dioxide  and  a  Want  of  Oxygen  on  the  Respiration 
and  the  Circulation.    Jour.  Physiol.,  June  30,  1908. 

Crowder,  T.  R.  :  A  Study  of  the  Ventilation  of  Sleeping 
Cars.    Arch.  Int.  Med.,  Jan.  15,  1911,  8o. 

Haldane  and  Smith:  The  Plwsiologic  Effects  of  Air 
Vitiated  by  Respiration.  J.  Path,  and  Bact.,  1892 
and  1893,  1,  168,  318. 

Erclents  Flugge:  Report  of  Experiments  at  the  Insti- 
tute of  Hygiene  at  Breslau.  Z.  f.  Hyg.,  1905,  363, 
388,  405,  433. 

Hill  and  Walker:  The  Relative  Influence  of  the  Heat 
and  Chemical  Impurity  of  Close  Air.  J.  Physiol., 
Nov.  9,  1910. 


INDEX 


Abdominal  distention,  29 
Abnormal  amplitude  during  maintenance,  88 
Abnormal  rate  during  maintenance,  8G 
Abnormal  respiration  due  to  Trendelenburg 

position,  89 
Abnormal  rhythm  during  maintenance,  87 
Abnormalities  of  respiration  in  recovery,  89- 

90 
Acapnia,  299 

Adenoids,  obstruction  from,  26 
Alcohol  chloroform  ether  mixture,  191—193 
Amplitude  of  respiration,  86—88 
Anaesthetist's  records,  318-320 
Anaesthesia  by  anoci  association,  244—248 
Anaesthesia,  place  of,  18 

preliminary  medication  in,  277-284 

signs  of,  82 
Anaesthetic  and  asthma,  35 

and  pneumonia,  35 

for  goitre  cases,  35 

history,  16 

period,  4—6 
Anoci  association,  244-248 
Apparatus,  Bennett,  139 

Connell,  153 

Flagg,  133-138 

Miller,  230 
Artificial  respiration,  90-97 
Aspirating  tongue  depressor,  327 
Aspirators,  321-327 
Asthma  with  anaesthesia,  35 
Atropine     and     morphine     preliminary     to 
ana'sthesia,  277-284 

Bennett  apparatus,  139 

method,  138-140 
Brachial  paralysis,  41-42 
Breathing  tube,  33-34,  317 
Bromides  preliminary  to  anaesthesia,  277 

Carbon  dioxide  and  cyanosis,  298-299 
and  rebrea thing,  296-307 
chemistry  of,  297-298 
effect  of  increasing  amount  in  blood, 

300-301 
effect  of  reducing  amount  in  blood, 

299 
in  the  blood,  297-298 
origin  of,  297-298 

percentage  to  cause  dyspnoea,  296 
percentage  to  stimulate  respiration, 

296 


Cardiac  massage,  119 
Cerebral  hemorrhage,  88 
Cheyne-Stokes  respiration,  88-90 
Chloroform,  185-200 

administration  of,  194 
containers  for,  194 
delayed  jjoisoning  with,  186-192 
testing  quality  of,  310 
Chloroform  anaesthesia,  apparatus  for,  194- 
195 
causes  of  death  in,  195-197 
general  considerations  of,  200 
mortality  in,  200 
position  for,  197-200 
present  status  of,  190-192 
signs  of,  197-199 
Chloroform  ether  anaesthesia,  193 
Chloroform  poisoning,  pathology  of,  186—192 
Circulatory  shock,  292 
Close  drop  method,  132 

as  compared  with  open  drop, 

140 
as    compared    with    semi-open 

drop,  141 
requirements  for,  132 
Coaxing  the  reflexing,  20 
Cocaine  solution  for  local  anaesthesia,  256 
Coccygeal  operations,  position  for,  43 
Combined  general  and  local  anaesthesia,  244- 

248 
Complete  anaesthesia,  curve  of,  12 

stages  of,  11 
Conductive  anaesthesia,  administration,  259 
Constant  maintenance,  control  of,  71 

pressure  of  vapor  delivered,  70 
volume  employed  in,  70 
Containers  for  nitrous  oxide,  201-202 
Control  of  vomiting,  79 
Color  signs,  97-102 

with  closed  method,  99-101 
with  jaundice,  101 
with  negroes,  101 
with  open  method,  99 
Conjunctivo-palpebral  reflex,  106 
Corneal  reflex,  106-107 
Cyanosis  and  carbon  dioxide,  298-299 
Cyanosis,  post-operative,  289 

Degeneration  of  liver  with  chloroform,  186- 

192 
Deviated  septum,  obstruction  from,  26 
Diaphragmatic  sign,  104 

337 


338 


INDEX 


Diet,  post-operative,  7,295 

preliminary,  17 
Diffusible  solution,  262 
Dilatation  of  sphincters,  28 
Distention,  abdominal,  29 
Driving  the  reflexes,  20 
Drop  bottle,  123 
Duties  of  Nurse  after  anaesthesia,  287 

before  anaesthesia,  285-287 

during  anaesthesia,  287 

Emergency  anaesthesia,  308—318 
accessories  to,  317 
chloroform  in,  314 
ethyl  chloride  in,  31Jr 
Endoneural  injection,  260 
Erb's  palsy,  -11 

Esmarch's  bandage,  anaesthesia  with,  251 
Estimating    amount    of    nitrous    oxide    in 

cylinder,  202 
Ether,  absorption  of,  66 

administration  of  by  oral  insuflBation,  121 

anaesthesia,  zones  of,  72 

cone,  311-313 

effect  on  viscera,  189, 190 

frolics,  4 

intravenous  administration  of,  174-180 

per  rectum,  169 

preparation    for    rectal    administration, 

169 
properties  of,  120 
rectal  administration  of,  172 
saturation,  26 
solution  for  intravenous  administration, 

311-313 
tension  in  body,  69 
testing  quality  of,  309 
vapor  tension  of,  6-4 
Ethyl  chloride,  lSl-184 

administration  of,  183, 184 
apparatus  for,  183 
dangers  of,  184 
freezing  with,  249,  250 
properties  of,  181 
Ethyl  chloride,  anaesthesia,  sequelae  of,  183 
Excitement  in  induction,  19 
Eyelid  signs,  103 
Eye  sign,  105 

Facepiece  for  open  drop  method,  122 
Flagg  apparatus,  133-138 

anaesthesia  with,  135 

features  of,  134 

induction  with,  135 

maintenance  with,  136 

recovery  with,  138 

vaporization  in,  134 


Flagg  method,  135-138 
First  surgical  anesthesia,  4 
Freezing  with  ethyl  chloride,  249,  250 

Gall  bladder  position,  43 
General  anaesthesia,  classes  of,  1 1 

definition  of,  9 

degrees  of,  11 

production  of,  9 
Glottis,  oedema  of,  26-34 
Goitre  cases  with  anaesthesia,  35 
Gwathmey  method  of  rectal  anaesthesia,  171- 
173 

Hemorrhage,  291 
cerebral,  88 
Henry's  law,  65 
History  of  anaesthesia,  1-6 
Hypercapnia,  299 
Hypodermoclysis,  technic  of,  117 
Hysteria,  292",  293 

Induction,  time  of,  12 
Improvised  breathing  cone,  311—313 
Improvised  breathing  tube,  317 
Incomplete  anaesthesia,  13 

curve  of,  13 
Induction,   15 
Induction,  periods  of,  15 
Infiltration  anaesthesia,  administration  of,  258 
Infusion,  technic  of,  114 
Intra-abdominal  administration  of  saline,  317 
Intrapharyngeal  insufflation,  149—158 

administration,  153—157 

apparatus  for,  150—156 

contra-indication,  158 

difficulties  of,  167 

improvised,  314—315 

indications  for,  158 
Intratracheal  insufflation,  159-169 

administration,  163-167 

advantages  of,  168 

apparatus  for,  161-163 

difficulties  of,  167 

disadvantages  of,  168 

improvnsed,  315,  316 
Intravenous  anaesthesia,  174-180 

administration  of,  177-179 

advantages  of,  179 

apparatus  for,  176 

disadvantages  of,  179, 180 

ether  solution  for,  175 

post-operative  treatment  in,  179 
Intubation,  technic  of,  164, 165 

Jackson  laryngoscope,  163  i 

Jaundice  in  anaesthesia,  101 


INDEX 


339 


Kidnej'  position,  43 

Kuatzu  inclhoil  of  resuscitation,  1181,  19 

Laryngoscope,  Jackson's,  163 

I^ewis"  pendulum  swing,  95 

Lid  reflex,  103,  10.),  10(i 

Liquid  method  of  oral  insufflation,  122 

Lithotomy  position,  5M 

Liver,   fatt\'  degeneration  with  chloroform, 

186-192 ' 
Ix)cal  anaesthesia,  249-260 

by  freezing,  219 

by  pressure,  2.50—251 

definition,  9 

needles  for,  257 

preliminary  treatment  for,  257-258 

production  of,  9-10 

solution  of  cocaine  for,  256 
novocaine  for,  25() 
quinine  and  urea  for,  256 

syringe  for,  257 

unusual  methods  of,  249-254 

usual  methods  of,  255-260 

Maintenance,  59-67 
constant,  60 
control  of,  61—63 
curve  of,  60-64 

vapor  tension  necessary  for,  67 
variable,  60-61 
Masseteric  sign,  102 

spasm,  290 
Methods  of  ansesthesia,  Bennett,  138-140 
Flagg,  135-138 
Gwathmev.  171-173 
Miller,  230 
Mixed  anesthesia,  9,  10,261,273 
definition  of,  9 
administration,  265-273 
advantages  of,  271 
apparatus  for,  263 
disadvantages  of,  273 
general  considerations  of,  261-265 
production  of,  10 
treatment  of  overdose,  268 
Morphine  and  atropine  preliminary  to  anaes- 
thesia, 277 
contra-indicated,  284 
indicated,  284 
scopolamin   preliminary   to   anaes- 
thesia. 277-281-284" 
Mortality  in  chloroform  antrsthesia,  200 
Mouth  wedge,  33 
Mucous,  removal  of,  34 
Muscular  signs,  102 
Musculospiral  paralysis,  41,  42 


Neck  operations,  position  for,  47 
Needles  for  local  an;esthesia,  257 
Negative  ventilation,  91 
Nitrous  oxide,  administration,  207,  208 
apparatus,  133-138 
containers  for,  201,  202 
preparation  of,  203-206 
Nitrous  oxide  oxygen  auicsthesia,  214-222 
administration  of,  218 
characteristics  of,  216 
color  in,  218 
eye  signs  in,  221 
physical  signs  in,  218-221 
preliminarv  medication  in, 

283 
pulse  in,  221 
relaxation  in,  220 
zones  of,  234 
Nitrous  oxide  oxvgen  ether  anresthesia,  223- 
248 
administration,  224-235 
administered   bv  constant 
flow,  230-233 
intermittent  flow,  225, 
229 
difficulties  in,  227,  229 
resume  of  100  cases,  236- 
244 
Nondiflusible  solution,  262 
Normal  respiration  with  ether  and  nitrous 
oxide,  84 
with  open  metho<l,  83 
Novocaine  solution  for  local  anaesthesia,  256 
Novocaine,  intravenous  injection  of,  251,  io'i 

Obstructed  respiration,  causes  of,  26 

control  of,  32 
OEdema  of  the  glottis,  26,  34 
Olfactory  vomiting,  control  of,  79 
Open  drop  method,  122,  127 

administration  of,  125 

advantages  of,  126 

apparatus  for,  122 

disadvantages  of,  127 

drop  bottle  for,  122 

facepiece  for,  122 

in  large  clinics,  141-145 
Oral  insufflation,  methods  of,  121,  122 

vapor  method,  145 
Orbital  signs,  108 

Paralysis,  brachial,  41,  42 

Erb's,  41 

musculospiral,  41,  42 

peroneal,  36 
Parson's  sign,  108 


340 


INDEX 


Patient,  point  of  view  of,  328-333 
Period  of  excitement,  15 

control  of,  19 
Periods  of  induction,  1 
Period  of  relaxation,  57 
Peroneal  paralysis,  36 
Pneumonia  and  ana?sthesia,  35 
Pneumonia,  post-operative,  295 
Polypi,  obstruction  from,  26 
Positive  ventilation,  92 
Post-operative  cyanosis,  289,  290 
diet,  295 

hysteria,  292,  293 
pneumonia,  295 
treatment  of  goitre  cases,  295 
vomiting,  288,  289 
Position  for  closure  of  abdominal  wound,  53 
coccygeal  operations,  43 
local  operations,  43 
neck  operations,  47 
rectal  operations,  43 
Trendelenburg,  36,  39 
Walcher,  53 
Pre-aniesthetic  period,  1—4 
Preliminary  diet,  17 

medication  in  anaesthesia,  17,  277-284 
nitrous  oxide  anaesthesia,  283 
visits,  16 

use  of  morphine,  58 
Protracted  unconsciousness,  293,  294 
Pressure  gauge,  92-95 
Pseudo  relaxation,  57 
Pseudo  rigidity,  25-29 
Pupillary  signs,  109-113 
in  induction,  110 
in  maintenance,  110-112 
in  recovery, 112-113 
Pulmonary  embolus,  88 
Pulse  in  nitrous  oxide  anaesthesia,  221 
signs,  113-119 
rate,  114 
rhythm,  113 
volume,  114 

Quinine  and  urea  for  local  anaesthesia,  256 

Rapid  induction,  conditions  necessary  for,  68 
Rate  of  recovery,  294 

respiration,  86 
Rebreathing.  296-307 
Records,  318-320 
Recovery,  74-81 

by  crisis,  75 

by  lysis,  75 

control  of,  76-81 

evidences  of,  74 

in  diabetes,  75 


Recovery,  stage  of,  74 

types  of,  75 
Recovery  room,  295 
Rectal  administration  of  ether,  16^174 
advantages  of,  173,  174 
apparatus  for,  171 
preliminary  treatment  for,  171 
solutions  used  in,  171 
Regional  anaesthesia,  administi-ation  of,  259 
Regional  intravenous  injection  of  novocaine. 

251,  252 
Relaxation,  causes  of,  58 
control  of,  59 
evidences  of,  57 

in  nitrous  oxide  oxygen  anaesthesia,  22C 
of  upper  eyelid,  103 
Removal  of  throat  tube,  77 
Respiratory  abnormalities,  85-88 
during  induction,  85 
maintenance,  86 
in  amplitude,  86,  88 
in  rhythm,  85,  87 
failure,  291 
symptoms,  82 
Restraint  diu"ing  induction,  22 
Resuscitation,  Kuatzu  method  of,  118,  119 
Rigidity,  24-35 
causes  of,  25 
control  of,  32 
Crile's  theory  of,  30 
evidences  of,  24 

from  dilatation  of  sphincters,  35 
from  intra-abdominal  distention,  56 
in  gall  bladder  cases,  28,  35 
in  induction,  24 
in  pelvic  operations,  28,  35 
Rose  position,  53 

Saliva,  removal  of,  34 

Saturation  with  ether,  26 

Scopolamin  and   morphine  preliminary   to 

anajsthesia,  277-281-284 
Semi-open  drop  method,  127-132 

advantages  of,  131 

apparatus  for,  128 

disadvantages  of,  132 
Shock,  292 
Shoulder  braces,  36 
Signs  of  anaesthesia,  82 

color,  97,  102 

diaphragmatic,  104 

eye,  105 

eyelid,  103 

masseteric,  102 

muscular,  102 

orbital,  108 

pupillary,  109,  113 


INDEX 


341 


Signs  of  anaesthesia,  Parson's,  108 

pulse,  li:}-119 
Simms'  position,  40 
Spasm  of  vocal  cords,  ?A 
Special  senses  during  induction,  ii 
Sphincters,  dilatation  of,  28 
Spinal  anaesthesia,  261-273 

administration  of,  265-268 

advantages,  271 

apparatus  for,  263 

disadvantages  of,  273 

general  considerations  of,  261—265 

treatment  of  overdose,  268 
Spinal  puncture,  treatment  of,  265-268 
Stages  of  anaesthesia,  11 
Stage  of  induction,  11 

maintenance,  12 

recovery,  12,  74 
Stopping  anaesthesia.  77 
Sylvester  method  of  artificial  respiration,  91, 

"  92,  94 
Syringe  for  local  anaesthesia,  257 


Tension  of  ether  in  body  during  anaesthesia, 

69 
Terminal  anaesthesia,  administration  of,  258 
Throat  tubes,  33,  34 

removal  of,  77 
Tongue  depressor  and  aspirator,  327 
Tonsils,  obstruction  from,  20 


Trendelenburg  position,  36-39 

contraindications,  39 

dangers  of,  39 

effect  on  respiration,  39 

indications  for,  39 

I)ulse  in,  77 
Turbinates,  obstruction  from,  26 
Types  of  aniesthesia,  9 

Urea  and  quinine  in  local  anaesthesia,  256 
Unconsciousness  protracted,  293,  294 

Vaporization,  64 

physics  of,  64,  65 
Vapor  method,  145-148 

apparatus  for,  146—148 
etlior  administered  by,  148 
oral  insufflation  with,  122 
Vapor  tension  of  ether,  64 
Ventilation,  negative,  92 

positive,  92 
Visit,  preliminary,  16 
Vocal  cords,  spasm  of,  34 
Vomiting,  control  of,  79 

post-operative,  288,  289 

olfactory,  79 
Vomitus,  removal  of,  34 

Walcher  position,  53 

Zones  of  ether  anaesthesia,  72 

Zones  of  nitrous  oxide  oxygen  anaesthesia,  234 


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